In the textbook on page 212 you will find the “Review Questions and Activities.” #2 has you “Imagine that you are setting up a cultural competence training…” 

Pg 212: #2- Image that you are setting up cultural competence training for doctors and nurses that would include knowledge and skill training, developmental training, integrated training, community-based training, and didactic training. How would you plan the overall training agenda? What sort of elements would you include? Leave out?

After reading Chapter 6 in the textbook and the two articles assigned for reading, one of which outlines standards and methods while the other gives an example of a training curriculum, write a general training agenda which includes:   

See two articles uploaded below:

1. Assessment (from last week’s readings) tests and/or exercises, as you learned last week

2. Important knowledge that cultural competence requires and each item here must be described and supported from the readings

3. Important skills that are required and each item here also must be described and supported from the readings

4. An example of how this training would be done (lean heavily on the “Four-Year Model…”)

Write your agenda in OUTLINE FORM. The four items above will be your main headings following a 1 paragraph introduction.

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A Four-Year Model Curriculum on Culture, Gender, LGBT, Religion, and
Spirituality for General Psychiatry Residency Training Programs in the United

States

Russell F. Lim, MD, Alan K. Koike, MD, David M. Gellerman, MD, PhD, Andreea L.
Seritan, MD, Mark E. Servis, MD, and Francis G. Lu, MD

Submitted to AADPRT for consideration for consideration for as a model curriculum on
Cultural Psychiatry, Friday, February 5, 2010

Revised May 3, 2010

Corresponding Author:

Russell F. Lim, MD
Health Sciences Associate Clinical Professor
Department of Psychiatry and Behavioral Sciences
University of California, Davis School of Medicine
2230 Stockton Blvd.
Sacramento, CA 95817
rflim@ucdavis.edu
916-874-4666
fax 916-875-1086

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Introduction

The increasing cultural diversity of the United States, as shown by the most recent

U.S. Census data, requires that clinicians understand how cultural differences affect

diagnosis and treatment. Between 1980 and 2000, the number of Asian Americans

increased by 230%, American Indians by 139%, Hispanic Americans by 142%, and

African Americans by 32%. In contrast, the Caucasian population increased by 11% (1).

In addition, Accreditation Council of Graduate Medical Education (ACGME)

requirements for psychiatric residents now include a familiarity with cultural assessment

(2), and the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-

TR) has added new emphasis to the influence of culture on diagnosis by including an

Outline for Cultural Formulation (OCF) and a Glossary of Culture Bound Syndromes (3).

Recent publications, such as the Surgeon General’s Supplement to the Report on

Mental Health, “Culture, Race, and Ethnicity”(2001) (4), which states that “culture

counts,” and the Institute of Medicine’s Unequal Treatment (2002) (5) indicate that

ethnic minority patients have less access to services and receive a lower quality of

medical and psychiatric treatment. Other documents such as the Culturally and

Linguistically Appropriate Services (CLAS) Standards (fourteen system standards about

culturally competent care, language access services and organizational supports for

cultural competence) (6); the Center for Mental Health Services (CMHS) report,

Managed Mental Health Care Services for Four Underrepresented/Underserved Groups,

(7); the California Endowment’s reports Principles and Recommended Standards for

Cultural Competence Education of Health Care Professionals – 2003 (8), A Manager’s

Guide to Cultural Competence Education for Health Care Professionals – 2003 (9), and

– 3 –

Resources in Cultural Competence Education for Health Care Professionals – 2003 (10);

the Commonwealth Fund Report (11); and the Clinical Manual of Cultural Psychiatry

(12) suggest ways in which we can train health and mental health professionals to provide

and to design culturally competent services, including evaluation of such services that are

appropriate for underserved patients.

Background Information and History

We believe that the success of our cultural curriculum has been due to three

factors: 1) A critical mass of committed ethnic minority faculty, 2) a supportive

administration, and 3) a diverse patient population. The Diversity Advisory Committee

(DAC) was founded in 1999 by its current Chair, Russell Lim, MD, to address and

develop diversity issues within the UC Davis Department of Psychiatry and Behavioral

Sciences. Our goals were to improve instruction in cultural competence in graduate and

undergraduate medical education; improve services for ethnic minority patients by

recruiting minority medical students, residents, and faculty; and to encourage scholarly

work such as publications and research. DAC has also supported the development of a

four-year Religion and Spirituality curriculum for the general psychiatry residency

program, which received a Templeton Foundation Curricular Award in 2003, as part of a

four-year Cultural Psychiatry curriculum. The American College of Psychiatrists (ACP)

awarded its Creativity in Psychiatric Education in 2007 to the UC Davis Department of

Psychiatry and Behavioral Sciences for the Diversity Advisory Committee. We have at

least two Grand Rounds Speakers per year who present on issues in cultural psychiatry.

Finally, we have conducted four successful Continuing Medical Education (CME)

symposiums in the last nine years, co-sponsored a fifth last year, as well as a Faculty

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Development Seminar that was held jointly with the University of California, San

Francisco, on cultural psychiatry topics.

Our other goals have been to recruit minority undergraduates, medical students,

residents and faculty to join the UC Davis School of Medicine and become teachers of

cultural psychiatry. We are active in interviewing medical school applicants, residency

applicants, and faculty applicants. DAC actively recruits residents to apply for the

American Psychiatric Association (APA) Minority Fellowships, and we have had ten

fellows in the last eleven years. We were also successful in recruiting Francis G. Lu, MD

to be the Luke and Grace Kim Endowed Professor in Cultural Psychiatry.

Finally, DAC encourages academic scholarship. Members of DAC have received

grants for research in geriatrics, and medical education and have published three articles

and an editorial in a special issue of Academic Psychiatry on Culture and Psychiatric

Education, and one in Adolescent Psychiatry, and have authored numerous book

chapters, as well given presentations nationally. Three of our members have been

honored for their contributions with the UC Davis Chancellor’s Award for Diversity and

Community.

The second key is administrative support. Our Chairman, Robert E. Hales, MD,

MBA, has been supportive from the beginning, by providing both a budget for our grand

rounds speakers, and providing us a seat on the Psychiatric Academic Council, which

oversees the academic mission of the department. The Residency Training Director

(Mark E. Servis, MD) has been equally supportive by allowing us to develop new

required courses in the Residency program. DAC now has several representatives on the

Training and Education Committee (TEC), which oversees residency training, including

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curriculum. However, no program can be successful without a core group of faculty.

DAC is an integral part of the infrastructure of the UCD Department of Psychiatry and

Behavioral Sciences and provides needed support for critical programs. Finally, DAC is

also an important part of the Dean’s Council on Diversity, and we hope to bring more

cultural competence to the medical center and medical school. DAC holds an annual

retreat in August to review goals from the previous year and to set goals for the next.

DAC meets monthly to encourage scholarly work and develop our projects agreed upon

at the annual retreat.

The clinical population in Sacramento County lends relevance to our educational

programs with its wide diversity of languages and cultures represented. For example, an

article in Time magazine called Sacramento the most diverse city in the United States in

September of 2002 (13). Sacramento County has seven threshold languages (Cantonese,

Hmong, Lao, Mien, Russian, Spanish, Vietnamese), as defined by the California Cultural

Competence Plan (14) as 5% of the Medicaid population or 3000 members, that speak

that language, which is second only to Los Angeles County, which has eight. Yet few of

the department’s educational activities in 1998 addressed the issues of how to serve a

culturally diverse population. We now feel that we can design and deliver a cultural

curriculum that can develop attitudes that support culturally competent care, teach

important cultural specific knowledge, and encourage the development of culturally

generic skills that lead to culturally appropriate assessment and treatment. Other

programs should perform a similar needs analysis of their patient population prior to

implementing a cultural competence curriculum, and make changes as their needs are

discovered and their resources are identified and developed.

– 6 –

Our approach can be stated simply as four guiding principles: 1) teach attitudes

that value acceptance of diverse cultural beliefs and worldviews, 2) demonstrate skills

that are culture generic, 3) teach knowledge that is culture specific, and 4) teach

culturally adapted techniques that are supported by evidence in peer-reviewed journals.

The sources for our inspiration are many, and this model curriculum represents the best

of what we have created in other settings added on to the original ACP award-winning

curriculum. We owe a great debt to the dedicated teachers that served as faculty in the

APA Annual Meeting Continuing Medical Education (CME) course entitled DSM-IV

Cultural Formulations: Assessment and Treatment, that the first author (RFL) directed

annually for thirteen years that led to the publication of the book Clinical Manual of

Cultural Psychiatry, which was based on the assumption that the use of the DSM-IV

OCF, along with culturally based knowledge would help to develop cultural competence.

We also acknowledge material developed and inspired by Sunita Mutha and Mary

Walton in their annual seminar at UCSF, Addressing Health Disparities: Cultural

Competency Faculty Development Program (15), which in turn inspired our second APA

Annual Meeting CME Course, Culturally Appropriate Assessment Made Incredibly

Clear- A Skills-based Course with Hands-On Experiences.

While the UC Davis cultural psychiatry curriculum is designed to be relevant for

the culturally diverse patient population seen by our general psychiatry residents, we

acknowledge there are inadequacies. To generalize its use in other general psychiatry

residency programs, as well as address under-represented topics, we have added sections

on Native American and LGBT topics to our model. The limitations to applying our

curriculum are that the curriculum should be tailored to the patient population seen, and

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be taught by faculty experienced with working with the identified ethnic groups.

Teaching all of the included material may exceed the available time in the residency

curriculum. In that case, we would suggest the prioritization of mental health disparities,

attitude development, skills development, general informational sessions, and cultural

formulation presentations. We would also suggest prioritizing the films, perhaps

omitting most films except The Color of Fear, in the most time-limited scenario. Some

of the psychotherapy material may be incorporated in a case conference format using the

DSM-IV-TR OCF, which would not take up any extra curricular time, as case

conferences are not thought of as being part of the formal didactic curriculum.

References

(1) CensusScope: 2000, http://www.censusscope.org/us/chart_race.html , accessed
February 5, 2010

(2) Accreditation Council of Graduate Medical Education: ACGME Program
Requirements for Graduate Medical Education in Psychiatry 2007.
http://www.acgme.org/acWebsite/downloads/RRC_progReq/400pr07012007 ,
accessed February 6, 2008

(3) American Psychiatric Association: Diagnostic and Statistical Manual, Fourth
Edition, Text Revision (DSM-IV-TR), APA, Washington, DC, 2000

(4) United States Department of Health and Human Services: Culture, Race, and
Ethnicity: A Supplement to Mental Health a Report of the Surgeon General, 2001,
http://www.surgeongeneral.gov/library/mentalhealth/cre/, accessed February 5,
2010

(5) Smedley BD, Stith AY, Nelson AR: Unequal Treatment: What Health Care
Providers Need to Know About Racial and Ethic Disparities in Healthcare. National
Academy Press, 2002, http://www.nap.edu/catalog/10260.html, accessed February
5, 2010

(6) Office of Minority Health: Culturally and Linguistically Appropriate Services
(CLAS) standards, 2000, http://www.omhrc.gov/clas/indexfinal.htm, accessed
February 5, 2010

(7) SAMHSA: Cultural Competence Standards in Managed Care Mental Health
Services: Four Underserved/Underrepresented Racial/Ethnic Groups. SMA00-3457,
2001, http://mentalhealth.samhsa.gov/publications/allpubs/SMA00-
3457/preface.asp, accessed February 5, 2010

(8) California Endowment: Principles and Recommended Standards for Cultural
Competence Education of Health Care Professionals – 2003a,

– 8 –

http://www.calendow.org/Collection_Publications.aspx?coll_id=26&ItemID=316,
click “View Report” below description, accessed February 5, 2010

(9) California Endowment: A Manager’s Guide to Cultural Competence Education for
Health Care Professionals. 2003b,
http://www.calendow.org/Collection_Publications.aspx?coll_id=26&ItemID=316,
click “View Report” below description, accessed February 5, 2010

(10) California Endowment: Resources in Cultural Competence Education for Health
Care Professionals. 2003c,
http://www.calendow.org/Collection_Publications.aspx?coll_id=26&ItemID=316,
click “View Report” below description, accessed February 5, 2010

(11) Betancourt, JR Green AR, Carrillo JE: Cultural Competence in Health Care:
Emerging Frameworks and Practical Approaches. The Commonwealth Fund,
October 2002,
http://www.commonwealthfund.org/usr_doc/betancourt_culturalcompetence_576.p
df, accessed February 05, 2010

(12) Lim RF, ed.: Clinical Manual of Cultural Psychiatry. Arlington, VA: APPI, 2006
(13) Stodghill R, and Bower A: Welcome to America’s Most Diverse City. Time,

Sunday, August 25, 2002,
http://www.time.com/time/nation/article/0,8599,340694,00.html, accessed February
3, 2010

(14) [California] DMH (Department of Mental Health) Information Notice No: 02-03.
Addendum for Implementation Plan for Phase II Consolidation of Medi-Cal
Specialty Mental Health Services — Cultural Competence Plan Requirements; 2003,
superseding [California] DMH Information Notice No: 97-14. Addendum for
implementation plan for phase II consolidation of Medi-Cal specialty mental health
services–cultural competence plan requirements, 1997.
http://www.dmh.cahwnet.gov/DMHDocs/docs/notices02/02-03_Enclosure ,
accessed February 16, 2008

(15) Mutha S, Walton N: Addressing Health Disparities: Cultural Competency Faculty
Development Program,
https://www.cme.ucsf.edu/cme/CourseDetail.aspx?coursenumber=MMC09019,
accessed February 4, 2010

Goals:

1. To fulfill 2007 ACGME RRC accreditation standards for general psychiatry
residency programs that focus on sociocultural issues (underlined and in italics)
for five of the six core competencies as follows:

1) Patient care
a) “Residents must have supervised experience in the
evaluation and treatment of patients. These patients should be of
different ages and gender from across the life cycle and from a
variety of ethnic, racial, sociocultural, and economic backgrounds.”
b) “Residents should develop competence in formulating a
clinical diagnosis for patients by conducting patient interviews,
eliciting a clear and accurate history; performing physical,
neurological, and mental status examination, including appropriate

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diagnostic studies; completing a systematic recording of findings;
relating history and clinical findings to the relevant biological
psychological, behavioral, and sociocultural issues associated with
etiology and treatment”

2) Medical knowledge
“The didactic curriculum must include the following specific
components:”
a) “the biological, genetic, psychological, sociocultural,
economic, ethnic, gender, religious/spiritual, sexual orientation,
and family factors that significantly influence physical and
psychological development throughout the life cycle”
b) “the fundamental principles of the epidemiology, etiologies,
diagnosis, treatment, and prevention of all major psychiatric
disorders in the current standard diagnostic statistical manual,
including the biological, psychological, sociocultural, and
iatrogenic factors that affect the prevention, incidence, prevalence
and long-term course and treatment of psychiatric disorders and
conditions”
c) “an understanding of American culture and subcultures,
particularly those found in the patient community associated with
the educational program, with specific focus for residents with
cultural backgrounds that are different from those of their patients”
d) “[the] use of case formulation that includes
neurobiological, phenomenological, psychological, and
sociocultural issues involved in diagnosis and management of
cases”

3) Interpersonal and communication skills
a) “Residents are expected to…. communicate effectively …, with
patients, their families, and the public across a broad range of
socioeconomic and cultural backgrounds”
b) “[Residents need to proficient at] demonstrating sensitivity and
responsiveness to a diverse patient population, including but not
limited to, diversity in gender, age, culture, race, religion,
disabilities, and sexual orientation”

4) Professionalism
a) “Residents are expected to demonstrate… sensitivity and
responsiveness to a diverse patient population, including but not
limited to, diversity in gender, age, culture, race, religion,
disabilities, and sexual orientation.”

5) Systems-based practice
a) “Residents are expected to advocate for quality patient care and
assisting patients in dealing with system complexities, including
disparity in mental health care”

Summarizing, our goals are:
1. To have trainees understand the impact of culture on assessment/formulation,

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diagnosis and treatment of mental disorders
2. To improve treatment outcomes of all patients by effectively bridging the
patient’s worldview and the clinician’s treatment plan and collaborating with the patient’s
social network
3. To reduce mental health disparities by teaching trainees specific skills and
knowledge to effectively treat all under-served groups

Objectives:
Skills:

Year One-Introduction to Cultural Psychiatry
1. To understand one’s own cultural identity

Year Two-Cultural Psychiatry
2. To able to use the DSM-IV-TR OCF to inform the clinical

interview, which includes many of the goals listed below
3. To assess a cultural identity
4. To assess an explanatory model
5. To assess religious/spiritual issues relevant to patient care
6. To interview patients regarding their spiritual/religious values,

beliefs, and practices with empathy and sensitivity, and incorporate
religious, spiritual and cultural issues in the differential diagnosis,
case formulation and treatment plan of patients when appropriate

7. To assess cultural stressors and supports
8. To assess the culture elements of the relationship between the

patient and clinician
9. To be able to use an interpreter effectively
10. To be able to recognize the impact of culture on symptom

presentation and assessment
11. To be able to recognize the impact of culture on treatment planning

Year Three-Psychotherapy and Culture
12. To understand how to adapt cognitive therapy and supportive

therapy to underserved populations, such as Cambodians and
Hispanics

Year Four- Advanced Cultural Psychiatry
13. To write and present a case presentation using the DSM-IV-TR

OCF
14. To be able to use a cultural consultant

Attitudes:
Year One
1. To understand their own cultural identity
2. To begin to understand one’s own cultural systems
3. To develop awareness and acceptance of differences between their

own worldview and those of others

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4. To understand how to take a spiritual/religious history and when to
ask for a more thorough assessment

5. To be aware of one’s own spiritual experiences and values, and be
willing to overcome personal biases and discomfort in addressing
spiritual/religious issues in patient care

6. To appreciate spiritual and religious diversity of their patients and
colleagues, while being sensitive and responsive of patients from a
variety of religious and spiritual backgrounds

7. To be respectful of the services provided by chaplains, clergy, and
spiritual leaders, including a willingness to collaborate in the
medical and emotional care of patients who are ill and/or dying,
and their families

8. To understand the culture of medicine and its impact on one’s
work and life

Year Two
9. To understanding the impact of racism, sexism, heterosexism, and

religious bias on patient’s lives

Knowledge: To understand the following topic areas
Year One

Introduction to spirituality and religion in psychiatry
1. The various ways of defining the terms “spiritual” and

“religious”
2. The research data on spiritual and religious beliefs and

practices on health care, especially mental health
3. The spiritual and religious worldviews that may be harmful or

distorted, and determine appropriate interventions and referrals
4. Approaches to critically assess and discuss the methodologies and

conclusions of the research data on spirituality and health care

Year Two-A Background History for Cultural Competence
1. Describe disparities in mental health treatment based on ethnicity
2. Definitions of common terms such as cultural competence,

diversity, culture, race, ethnicity, linguistic access, mental health
and healthcare disparities

3. Use primary sources to describe the evidence for mental health and
healthcare disparities

4. Describe pertinent national and state regulations and policies
regarding culturally and linguistically appropriate health care and
services (i.e., USDHHS, Office of Minority Health (CLAS), Office
of Civil Rights, LEP)

5. Describe how culture shapes health beliefs and values
6. Describe how culture affects help-seeking behaviors and decision-

making
7. Discuss how cross-cultural communication and medical

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interpreters can affect the use of health services and outcomes
8. Rationale for using an interpreter

a. Improving the quality of care
b. Better health outcomes
c. Compliance with legal regulations (i.e., Title VI of the Civil

Rights Act)
9. The resident will learn culture specific knowledge about patient

populations generally seen, such as historical facts such as reasons
for immigration, and basic cultural beliefs and cultural gender and
family roles, as well as differing cultural presentations of illness
and culture bound syndromes concerning:
a. African Americans
b. Asian Americans
c. Hispanic Americans
d. Native Americans
e. LGBT individuals
f. Women’s’ Health and Mental Health

10. The effect of race/ethnicity on pharmacology
11. Cultural aspects of depression

Year Three
12. Understand how to formulate psychotherapy cases by stages of

acculturation, racial identity, self identity, and communication styles
13. Learn psychotherapy techniques to use with patients from diverse cultures
14. Be able to identify intra-ethnic and inter-ethnic transference and counter

transference
15. The effect of race/ethnicity, gender, and sexual orientation,

amongst other cultural identity variables in psychotherapy with:
a. African Americans
b. Asian Americans
c. Hispanic Americans
d. Native Americans
e. LGBT individuals
f. Women

Spiritual/religious issues in psychotherapy
1. Recognize when exploration of spiritual/religious issues may be

valuable
2. Understand the difference between healthy and normative spiritual

or religious phenomenon from that which is unhealthy and
psychopathological

3. Understand the value of patients’ spirituality/religion as a source of
strength/support and positive coping, versus a source of stress and
negative coping

– 13 –

4. Understand types of transference and counter-transference that
may occur when exploring spiritual and religious issues with
patients, and its effect upon therapy

5. Interview patients regarding their spiritual or religious values,
beliefs, and practices with empathy and respect

6. Incorporate spiritual/religious issues in the differential diagnosis,
case formulation, and treatment plan of patients, when appropriate

7. Address issues of transference and counter-transference, and
determine appropriate interventions, including when the therapist’s
religious/spiritual affiliations are questioned

8. Be aware of one’s own spiritual/religious experiences and values,
and how it may influence their consideration of the spiritual/
religious issues of patients

9. Recognize when patients may benefit from either further
spiritual/religious assessment and from utilizing religious or
spiritual resources, including referral to clergy or pastoral
counseling

Advanced Cultural Psychiatry- PGY-4
1. The resident will be able to write and present a case in the DSM
-IV-TR OCF.
2. The resident will be able to use a cultural consultant to further

explore a case from his or her own caseload.

Bibliography-Resources
1. Accreditation Council for Graduate Medical Education: Residency

Review Committee, Guidelines for Psychiatric Residencies, 2007.
Available at www.acgme.org/acWebsite/downloads/RRC_progReq/
400pr07012007 , 2007

2. SAMHSA: Cultural Competence Standards in Managed Care Mental
Health Services: Four Underserved/Underrepresented Racial/Ethnic
Groups, http://mentalhealth.samhsa.gov/publications/allpubs/sma00-
3457/, 2001

3. Smedly BD, Stith AY, Nelson AR (Eds.): Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care. Washington,
DC: National Academy Press. 2003

4. Lurhmann TM: Of Two Minds: An Anthropologist Looks at American
Psychiatry. New York, NY: Random House, 2001

5. Pinderhughes E: Understanding Race, Ethnicity, and Power: The Key to
Efficacy on Clinical Practice. New York, NY: Free Press, 1989

6. Koenig H: Spirituality in Patient Care: Why, How, When, and What, 2nd
Edition, Philadelphia, PA: Templeton Foundation Press, 2006

7. Koenig, HG and Sloan, RP. Pro & Con: Should physicians conduct
spiritual histories of their patients? Clinical Psychiatric News, Volume 32,
Issue 3, Page 20, 2004

8. Pulchalski C: Spiritual assessment in clinical practice. Psychiatric Annals,

– 14 –

36: 150-5, 2006
9. Lim RF, Lu FG, Hilty DM: The Impact of Social Inequalities on Health

Care. In Behavior and Medicine, 5th Edition, In Wedding D, Stuber ML,
(Eds.) Cambridge, MA: Hogrefe and Huber, 2010

10. Lim RF: The Role of Cultural Competence. In Ruiz P, Primm A, (Eds.)
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14. Lim RF, (Ed.): Clinical Manual of Cultural Psychiatry. Arlington, VA:
APPI, 2006

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Using the DSM-IV-TR Outline for Cultural Formulation, Davis, CA: UC
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20. Lim RF, Diamond RJ, Chang JB, Primm AB, Lu FG: Using non-feature
films to teach diversity, cultural competence, and the DSM-IV-TR outline
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21. Lee MW: The Color of Fear. Berkeley, CA: Stir Fry Productions, 1995
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2003
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Productions, Brooklyn, NY, 2002

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28. Hays PA: Addressing Cultural Complexities in Practice: Assessment,
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38. Kinzie, JD: Psychotherapy for massively traumatized refugees: the
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40. Otto MW, Hinton DE: Modifying exposure-based CBT for Cambodian
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Practice, Volume 13, Issue 4, November 2006, Pages 261-270

41. Interian A, Díaz-Martínez, AM: Considerations for culturally competent

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cognitive-behavioral therapy for depression with Hispanic patients.
Cognitive and Behavioral Practice, 14:1, 2007, Pages 84-97

42. Gone, JP: Psychotherapy and traditional healing for American Indians:
Exploring the prospects for therapeutic integration. The Counseling
Psychologist. 38: 2, 166-235, 2010

43. Koenig, HG and Pritchett, J. Religion and psychotherapy. In, Koenig, HG
(Ed.) Handbook of Religion and Mental Health. San Diego: Academic
Press, 1998

44. McAuliffe G, et al: Culturally Alert Counseling: A Comprehensive
Introduction. (DVD included with book). Thousand Oaks, CA: Sage
Publications, 2008

45. Romans SE and Seeman MV: Women’s Mental Health: A Life Cycle
Approach. Philadelphia, PA: Lippincott Williams and Wilkins, 2006

46. Arredondo P: Multicultural Counseling Video Series: Counseling
Latina/Latino Clients, Washington, DC: American Psychological
Association, 2005

47. Arredondo PM: Latina/Latino Counseling & Psychotherapy: Specifics of
Practice for Counseling with Latina/os – North Amherst, MA:
Microtraining Associates, 1994

48. Gill RM, Vasquez CI: The Maria Paradox, New York, NY: G. Putnam’s
Sons, 1996

49. Parham TA: Multicultural Counseling Video Series: Working With
African American Clients, Washington, DC: American Psychological
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50. Parham TA: Managing Therapeutic Issues with African-American Clients.
North Amherst, MA: Microtraining Associates, 1992

51. Parham TA: Counseling Persons of African Descent: Raising the Bar of
Practitioner Competence. Thousand Oaks, CA: Sage Publications, 2002

52. Lu FG: Saving Face: Recognizing and Managing the Stigma of Mental
Illness in Asian Americans. Sacramento, CA: Mental Health Association
in California, 1127 11th Street, Suite 925, Sacramento, CA 95814, see
http://www.mhac.org/barriers/antistigma.cfm

53. Tseng WS, Strelzer J: Culture and Psychotherapy: A Guide to Clinical
Practice. Washington, DC: American Psychiatric Press, Inc., 2001

54. Bhui K, Morgan N: Effective psychotherapy in a racially and culturally
diverse society, Advances in Psychiatric Treatment, 13: 187-193, 2007

55. Cardemil EV, Battle C: Guess who’s coming to therapy? Getting
comfortable with conversations about race and ethnicity in psychotherapy.
Professional Psychology: Research & Practice, 34, 278-286, 2003

56. Comas-Diaz L, Jacobsen FM: Ethnocultural transference and
countertransference in the therapeutic dyad. Am J Orthopsychiatry,
61:392–402, 1991

57. Hsu J, Tseng, WS: Intercultural psychotherapy. Archives of General
Psychiatry, 27, 700–705, 1972

58. Kirmayer LJ: Psychotherapy and the cultural concept of the person.
Trancult Psychiatry, 44: 232-257, 2007

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59. Lewis DK: A cross-cultural model for psychotherapy: Working with the
African-American client. Cultural Diversity and Ethnic Minority
Psychology, 6:2, 1996

60. Poston WSC, Craine M, Atkinson DR: Counselor dissimilarity
confrontation, client cultural mistrust, and willingness to self-disclose. J
MultiCult Couns Dev, 19, 65-73, 1991

61. Seeley K: The listening cure: listening for culture in intercultural
psychological treatments, Psychoanal Rev, Jun;92(3):431-52, 2005

62. Tummala-Narra P: Dynamics of race and culture in the supervisory
encounter. Psychoanalytic Psychology, 21:2, 300–311, 2004

63. Bland IJ, Kraft IK: The therapeutic alliance across cultures. In Okpaku, S,
ed., Clinical Methods in Transcultural Psychiatry. Washington, DC,
APPI, 1998

64. Chin, JL: Toward a psychology of difference: psychotherapy for a
culturally diverse population. In Chin JL, De La Cancela V, and Jenkins
YM, Eds: Diversity in Psychotherapy: The Politics of Race, Ethnicity, and
Gender, edited by. Westport, CT: Praeger Publishers, 1993

65. Foulks EF, Bland IJ, & Shervington D: Psychotherapy across cultures. In
Oldham JM and Riba M (Eds.), Annual Review of Psychiatry (Vol. 14,
pp. 511–528). Washington, DC: American Psychiatric Press, 1995

66. Sue DW, Sue D: Counseling the Culturally Diverse: Theory and practice,
5th Edition. New York: J. Wiley, 2007

67. Yamamoto J, Silva JA, Justice LF, Chang CY, Leong GB: Cross-cultural
psychotherapy, in Gaw AC, ed, Culture, Ethnicity, and Mental Illness.
Washington, DC: American Psychiatric Press, 1993

68. Lewis-Fernandez R, Diaz N: The cultural formulation: A method for
assessing cultural factors affecting the clinical encounter, Psychiatric
Quarterly, 73: 4, pp 271-95, 2002

69. Cheung F, Lin KM: Neurasthenia, depression and somatoform disorder In
a Chinese-Vietnamese woman migrant. Culture, Medicine, and Psychiatry,
21: 247–258, 1997

70. McGoldrick M, Giordano J, Garcia-Preto N: Ethnicity and Family
Therapy, 3rd Edition, New York: Guilford Press, 2005

71. Lu FG: Annotated Bibliography of Cultural Psychiatry and Other Topics,
in Lim RF (ed.) Clinical Manual of Cultural Psychiatry. Arlington, VA:
APPI, 2006, pp 271-290

72. Diamond M, Sigmundson HK: Sex reassignment at birth: Long-term
review and clinical implications. Arch Pediatr Adolesc Med 15:298-304,
1997

73. Colapinto J: Gender Gap: What were the real reasons behind David
Reimer’s suicide? Slate, June 3, 2004

74. Colapinto J: The true story of John/Joan. Rolling Stone; Dec 11, 54-97.
(available at http://www.infocirc.org/rollston.htm), 1997

75. Tyson P: A developmental line of gender identity, gender role, and choice
of love object. J Amer Psychoanal Assn 30:61-80, 1982

76. Cahill L: Why sex matters for neuroscience. Nature Reviews Neuroscience
7:477-484, 2006

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77. Hampton T: Researchers tap into the male brain. JAMA 296:2301-2302,
2006

78. Atkinson S, Gabbard GO: Erotic transference in the male adolescent-
female analyst dyad. Psychoanal St Child 50:171-186, 1995

79. Hobday G, Mellman L, Gabbard GO: Complex sexualized transferences
when the patient is male and the therapist female. Am J Psych 165:1525-
30, 2008

80. Gabbard GO: Sexual excitement and countertransference love in the
analyst. J Amer Psychoanal Assn 42:1083-1106, 1994

81. Person E: Transference love and romantic love. In: Dreams of Love and
Fateful Encounters. New York, Penguin Books, 1988, pp. 241-264

82. Tinsley JA, Mellman LA: Patients’ reactions to a psychiatrist’s pregnancy.
Am J Psych 160:27-31, 2003

83. Mogul KM: The sex of the therapist. Am J Psych 139:1-11, 1982
84. World Professional Association for Transgender Health: Standards of Care

(available at: http://www.wpath.org/publications_standards.cfm)
85. Soares C: The menopausal transition and depression: a window of

vulnerability? Menopause Management March-April, 13-25, 2008
86. Goldstein SR, Stuenkel CA: The long and winding road of hormone

therapy: Where are we today? Women’s Health Update, Special
supplement, March-April, 1-11, 2008

Optional readings:

87. Brizendine L: The Female Brain. NY, Morgan Road Books, 2006
88. Diamond MJ: Masculinity unraveled. J Amer Psychoanal Assn 54:1099-

1130, 2006
89. Ulberg R, Johansson P, Marble A, Hoglend P: Patient sex as moderator of

effects of transference interpretation in a randomized controlled study of
dynamic psychotherapy. Can J Psych ; 54:78-86, 2009

90. Nadelson CC, Notman MT: Gender issues in psychiatric treatment. In
Gabbard GO. (Editor): Treatment of Psychiatric Disorders, 3rd Ed.
Arlington, VA. American Psychiatric Publishing, 2001, pp. 21-45.

91. McWilliams N: Therapy across the sexual orientation boundary:
Reflections of a heterosexual female analyst on working with lesbian, gay,
and bisexual patients. Gender and Psychoanalysis 1:203-221, 1996

Instructional Methods

1) Cultural Identity Awareness Exercise- Ask participants to first self-reflect on

their current cultural identity, and then introduce themselves considering many possible

cultural identity variables: where they are from, what language (s) they speak,

race/ethnicity, gender, sexual orientation, socioeconomic status, educational attainment,

spiritual/religious beliefs, roles that they play in their life, among others. This exercise

– 19 –

can also be done in pairs first by noting the cultural identity differences between the two

persons. Finally, the pairs could share their cultural identity similarities and differences

with others in the group. The leader(s) of this exercise may wish to model this process

first to facilitate the participants’ engagement. A second exercise would be for each

person to self-reflect on the development of their cultural identity over time and location

changes focusing on times when differences were experienced between the person and

others. Then, as with the first exercise, pairs could start the process to discuss between

them their experiences of differences and its impact on cultural identity development, and

finally sharing can take place in the larger group. This second exercise can also be

modeled first by the leader(s).

2) Lectures on cultural generic assessment techniques organized with the DSM-

IV-TR OCF and discussion about cases (both published and current unpublished

ones), which exemplify the use of the OCF.

A. Cultural identity of the individual with standardized patient,

B. Cultural idioms of distress, culture bound syndromes, explanatory models, and

treatment pathways with standardized patient,

C. Cultural stressors and supports with standardized patient,

D. Cultural elements of the relationship between the clinician and the individual.

E. Overall assessment for differential diagnosis and treatment planning with

standardized patient.

3) Lectures and discussion on culturally specific knowledge issues.

4) A journal club can supplement site-specific learning, as would case

conferences using the DSM-IV-TR OCF. Residents are expected to write and present

– 20 –

cases incorporating the OCF.

5) Videos as a stimulus for discussion. Examples include: The Color of Fear to

discuss racism (Lim, Diamond, Chang, et al), For the Bible Tells Me So, to discuss

homophobia, The Alternative Fix, to discuss complimentary and alternative medicine,

The Pill, to discuss women’s health issues, The Culture of Emotions, to discuss the DSM-

IV-TR OCF, and Saving Face: Recognizing and Managing the Stigma of Mental Illness

in Asian Americans, to discuss the stigma of mental illness in Asian Americans.

6) Videotaped case material showing a demonstration of skills, followed by a

practice session with a standardized patient, followed by formative evaluation with

standardized patients.

7) Online learning, such as the use of the Association of Gay and Lesbian

Psychiatrists, LGBT Mental Health Syllabus at http://www.aglp.org/gap.

Instructor Preparation

Instructors must be familiar with the main concepts of cultural competence,

including mental health/healthcare disparities, federal and state initiatives, and be aware

of their own cultural identity and biases. All instructors should be familiar with the

curricular material, and would be expected to have completed a cultural identity

awareness exercise, complete reading of articles and viewing of tapes. The instructor

would receive training in evaluating cultural assessment skills with the use of

standardized patients. Instructors will also be given a training entitled- “A Train the

Trainer’s Workshop.” Ideally, instructors should have clinical experience in working with

culturally diverse patients including from ethnic minority groups.

– 21 –

Expectations of Learners

Learners are expected to approach the curriculum with an open mind, to share

personal experiences with racism and other biases based on cultural identity and working

with other cultural groups, to be mindful of cultural factors in all patient interactions, to

read all articles prior to lecture, and to bring in case examples for discussion using the

DSM-IV-TR OCF.

Creativity and Innovation

Our curriculum is comprehensive and developmental. It recognizes that culture

specific knowledge is necessary but insufficient as well as potentially promoting

stereotypes when it is the sole focus of the curriculum. Culture generic cultural

competence skills must be demonstrated, taught, and evaluated for a minimum level of

proficiency. It emphasizes the concept of “just in time” learning, or developmentally

appropriate objectives which teaches the concepts at a time in their training when

residents are most likely to use them, such as psychotherapy skills during the usual third

year outpatient experience. The curriculum emphasizes actual performance and

evaluation of skills using standardized patients in lecture and informative evaluation. We

have created our own training materials with a unique set of videotaped cases using a

Caucasian interviewer and standardized patients to demonstrate the use of the OCF in

interviewing.

Course outlines

Two Phases:
Culture-generic skills and attitudes, then culture-specific knowledge.

Year one

– 22 –

Cultural identity awareness and the culture of medicine (Lurhman)

Cultural introductions
Discussion Group Questions for Cultural Identity Awareness Exercise

(Modeled after E. Pinderhughes)
1. What is your cultural identity?
2. What was your first experience with feeling different?
3. What is your ethnic background?
4. What has it meant to belong to your ethnic group?
5. How has it felt to belong to your ethnic group?
6. What do you like about your ethnic identity?
7. What do you dislike?
8. What are your feelings about being White or a person-of-color?
9. How do you think others feel?

Spiritual History and Assessment- 2 sessions (Koenig, Koenig and Sloan,
Pulchalski)

Year two
Rationale for cultural competence, (ACGME, RRC accreditation core

competences on sociocultural issues)
Health and mental health disparities (Lim, Lu, Hilty) (Lim)

Supplement to Surgeon General’s Report on Mental Health (USDHHS)
Unequal Treatment (Smedley, et al)
The business case for cultural competence (Brach, Frasierrector)

Stereotypes vs. Generalizations (Mutha, Welsch)
CLAS standards (OMH)

The DSM-IV-TR Outline for Cultural Formulation and assessment skills

(APA, Caraballo, et. al., Ton, Lim)
Cultural Identity:

The “Addressing” acronym (Hays) is a good starting point for the
assessment of cultural identity.

Age and generational influences
Developmental and acquired
Disabilities
Religion and spiritual orientation
Ethnicity
Socioeconomic status
Sexual orientation
Indigenous heritage
National origin
Gender

Additional cultural identity variables to consider:
1. Language (s) spoken or preferred
2. Acculturation

– 23 –

3. Gender/ Gender Identity
4. Ethnicity
5. Nationality
6. Sexual orientation
7. Religious or spiritual group
8. Political orientation
9. Vocational identity
10. Geographic location (i.e., rural, urban, suburban)

How? Developmental, social history, or direct questioning.
Standardized Patient exercise- Part A of OCF

Idioms of Distress
1. Dizziness
2. Fatigue
3. Pain- headaches, backaches, stomach aches
4. Evil spirits

Culture Bound Syndromes
1. Ataque de Nervios

2. Neurasthenia (Shenjing Shuairuo)
Explanatory Models (Ton, Lim)

1. Magic- Evil Eye
2. Religious- Punishment
3. Moral- Laziness, selfishness, weak will
4. Medical-Ayurveda, Chinese Traditional Medicine,

Homeopathy, osteopathy, herbal treatments, etc.
5. Psychological Stress

Kleinman’s Questions (Kleinman)
1. What do you call your illness? What name does it have?
2. What do you think has caused the illness?
3. Why and when did it start?
4. What do you think the illness does? How does it work?
5. How severe is it? Will it have a short or long course?
6. What kind of treatment do you think the patient should

receive? What are the most important results you hope she
receives from this treatment?

7. What are the chief problems the illness has caused?
8. What do you fear most about the illness?
Standardized Patient exercise- Part B of OCF

Standardized patient exercise- Part C- Cultural stressors and supports,
spiritual assessment

Film example Part D- (Bland or Lim, Lu cases)
Standardized Patient exercise- Part E- Explaining the treatment plan,
including the patient’s explanatory model and LEARN (Caraballo, et al)

The Culture of Emotions- The DSM-IV-TR OCF (Lu, Koskoff)
The Color of Fear- Exploring feelings about racism (Lee Mun Wah)

– 24 –

How to use an Interpreter (Lee)
American culture-Our culture and what it means to others
Chapters from Clinical Manual of Cultural Psychiatry
Ethnopsychopharmacology (Smith)

African Americans (Primm)
Asian Americans (Du)
Hispanic Americans (Laria, Lewis-Fernandez)
Native Americans (Fleming)
Trauma and Substance Abuse
LGBT- (AGLP- LGBT Curriculum)

The History of Psychiatry and Homosexuality
Taking a Sexual History with LBGT Patients
Psychological Development & Life Cycle
Psychotherapy
Medical and Mental Health
Transgender
Intersex
Diversity / People of Color

Culture and Depression (Lim, Ton)

Journal club: Explanatory models (Kleinman), Racism and misdiagnosis
(Adebimpe), Cognitive behavioral therapy (Otto and Hinton, Hinton and Otto),
Ethnography (Culhane Pera K), PTSD and Latinos.

Formative evaluation with standardized patients and feedback on videotaped
interview, focusing on verbal and non-verbal communication.

Year Three
Adapting psychotherapy techniques and assumptions (references 43-68)

Introduction to psychotherapy and culture
Definitions
Assumptions in Western psychotherapy
Acculturation

Communication and listening culturally
Norms
Techniques
Barriers to multi-cultural therapy
Communication style differences
Ethnocultural transference and counter-transference (Comas Diaz, Jacobsen)
Supervision and ethnicity (Tumula-Nara)
Identity- Racial identity and cultural self-identity
Practical clinical strategies
Culturally Alert Counseling: A Comprehensive Introduction- DVD (McAuliffe)
Saving Face: Recognizing and Managing the Stigma of Mental Illness in Asian

Americans- Lu

Russell Lim� 5/4/10 1:28 AM
Formatted: Bullets and Numbering

Russell Lim� 5/4/10 1:28 AM
Formatted: Bullets and Numbering

– 25 –

Video Case examples- Strategies to overcome Barriers to effective psychotherapy
Hispanic issues in psychotherapy- (Arrendondo)
The ten commandments of marianismo
Spanish phrases and metaphors
Psychotherapy and African Americans (Parham)

Rituals and symbols
“Life at its best is a creative synthesis of opposites in fruitful
harmony.”

Examples
Cognitive Therapy in Cambodians- (Otto and Hinton, Hinton and Otto)

` CBT in Hispanics- (Interian, Díaz-Martínez)
The therapist variable- (Kinzie)

Group therapy with Vietnamese patients- (Truong and Gutierrez)
Therapy in African Americans- (Parham, Bland, Post)
Therapy in Latinos- (Arendondo)
Therapy in Native Americans- The use of Ritual in therapy (Gone)

Case Conferences incorporating the DSM-IV-TR OCF

Year Four
Gender and Sexuality
Gender identity in development- watch and discuss excerpts from BBC

Documentary,“7 & Up.”
Erotic transference and counter-transference- watch and discuss vignette

from HBO series, “In Treatment.”
Female and male sexual dysfunction
Paraphilias
The effect of psychotherapist gender on therapeutic alliance
Gender Identity and Transgender health and mental health
Perimenopause
Sexual side effects of psychotropic medications

Advanced Cultural Psychiatry- Each senior resident presents a case incorporating
the DSM-IV-TR OCF with a cultural consultant present to facilitate
discussion (Lewis-Fernandez and Diaz, Chung and Lin, McGoldrick,
Giordano and Garcia-Preto)

AComprehensive Framework and
Preferred Practices for Measuring and
Reporting Cultural Competency
A CONSENSUS REPORT

NQF
NATIONAL QUALITY FORUM

CULTURAL
COMPETENCY

J. Emilio Carrillo, MD, MPH
(Co-Chair)

NewYork-Presbyterian Hospital and
Healthcare System

New York, NY

Winston F. Wong, MD, MS (Co-Chair)
Kaiser Permanente
Oakland, CA

Dennis P. Andrulis, MPH, PhD
Center for Health Equality
Drexel University
Philadelphia, PA

Francesca Gany, MD, MS
Center for Immigrant Health
New York University School of Medicine
New York, NY

Tawara D. Goode, MA
National Center for Cultural Competence
Georgetown University
Washington, DC

Sarah Hudson Scholle, DrPH, MPH
National Committee for Quality Assurance
Washington, DC

Deeana L. Jang
Asian and Pacific Islander American Health

Forum
Washington, DC

Boris Kalanj
Children’s Hospitals and Clinics of Minnesota
Minneapolis, MN

Sunita Mutha, MD
University of California, San Francisco
San Francisco, CA

Dula F. Pacquiao, EdD, RN
University of Medicine and Dentistry
New Jersey School of Nursing
Newark, NJ

Tanya Pagán Raggio-Ashley, MD, MPH
Office of Minority Health & Health

Disparities
Health Resources and Services

Administration
Rockville, MD

Marsha Regenstein, PhD
School of Public Health and Health Services
George Washington University
Washington, DC

Paul M. Schyve, MD
The Joint Commission
Oakbrook Terrace, IL

Rachel Wallace Tellez, MD, MS
American Academy of Pediatrics/Community

Clinics, Inc.
Silver Spring, MD

Beverly A. Weidmer, MA
RAND
Santa Monica, CA

Kimberlydawn Wisdom, MD, MS
Henry Ford Health System
Detroit, MI

Mara K. Youdelman, JD
National Health Law Program
Washington, DC

Consultant
Robert Weech-Maldonado, PhD, MBA

University of Florida
Gainesville, FL

PROJECT STAFF
Fatema Salam, MPH

Senior Program Director

Robyn Y. Nishimi, PhD
Senior Advisor

Nicole W. McElveen, MPH
Program Director

Helen Burstin, MD, MPH
Senior Vice President,

Performance Measures

CULTURAL COMPETENCY STEERING COMMITTEE

A Comprehensive Framework and Preferred Practices
for Measuring and Reporting Cultural Competency:
A Consensus Report

Foreword

EQUITY IS WIDELY ACCEPTED as a core aim of healthcare quality. Yet, disparities in the
provision of healthcare in the United States are severe and pervasive, despite widespread
documentation and numerous attempts to address them. Racial and ethnic minorities face
disproportionately higher rates of disease, disability, and mortality. African Americans have
higher death rates from heart disease, diabetes, AIDS, and cancer, and American Indians
and Alaskan Natives have lower life expectancies and higher rates of infant mortality.

In order to reduce disparities and improve outcomes, a number of healthcare organiza-
tions are exploring ways to improve cultural competency—that is, to ensure that diverse
patient populations receive high-quality care that is safe, patient and family centered,
evidence based, and equitable.

The National Quality Forum (NQF), an organization dedicated to improving healthcare
quality, has endorsed 45 practices to guide healthcare systems in providing care that is
culturally appropriate and patient centered. This report presents those practices along with
a comprehensive framework for measuring and reporting cultural competency, covering
issues such as communication, community engagement and workforce training, and providing
healthcare systems with practices they can implement to help reduce persistent disparities in
healthcare and create higher-quality,

more

patient-centered care. This framework and these
preferred practices were vetted through NQF’s Consensus Development Process, granting
them special legal status as voluntary consensus standards.

The aim to reduce disparities and create more patient-centered, culturally competent care
directly aligns with the goals of the National Priorities Partnership—a diverse coalition of
28 major national organizations representing those who pay for, receive, provide, and
evaluate healthcare. NQF is both the convener and a member of this coalition that was
formed to transform healthcare from the inside out.

NQF thanks the Cultural Competency Steering Committee and NQF Members for their
efforts in helping achieve a healthcare system that recognizes that truly high-quality care is
also culturally competent care.

National Quality Forum i

Janet M. Corrigan, PhD, MBA
President and Chief Executive Officer

National Quality Forum i

National Quality Forum

This work was supported by The California Endowment (www.calendow.org) and
The Commonwealth Fund (www.cmwf.org).

Recommended Citation: National Quality Forum (NQF). A Comprehensive Framework and
Preferred Practices for Measuring and Reporting Cultural Competency: A Consensus Report.
Washington, DC: NQF; 2009.

© 2009. National Quality Forum
All rights reserved

ISBN: 978-1-933875-28-

6

No part of this report may be reproduced, stored in a retrieval system, or transmitted, in
any form or by any means electronic, mechanical, photocopying, recording, or otherwise,
without prior permission of the National Quality Forum. Requests for permission to reprint
or make copies should be directed to:

Permissions
National Quality Forum
601 13th Street NW

Suite 500 North
Washington, DC 20005

Fax 202-783-34

34

www.qualityforum.org

The mission of the National Quality Forum is to improve the quality of American
healthcare by setting national priorities and goals for performance improvement,
endorsing national consensus standards for measuring and publicly reporting on
performance, and promoting the attainment of national goals through education
and outreach programs.

ii National Quality Forum

A Comprehensive Framework and Preferred Practices
for Measuring and Reporting Cultural Competency:
A Consensus Report

Table of Contents

Executive Summary ………………………………………………………………………………………. v

Framework for Measuring and Reporting Cultural Competency ……………………………….. 1
Introduction…………………………………………………………………………………………….. 1
Purpose ………………………………………………………………………………………………….

2

Defining Cultural Competency……………………………………………………………………… 2
Identifying the Framework ………………………………………………………………………….. 4
Purpose of the Framework ………………………………………………………………………….. 4
Guiding Principles ……………………………………………………………………………………. 5
Framework Domains and Subdomains …………………………………………………………… 5

Preferred Practices for Measuring and Reporting Cultural Competency ……………………. 15
Introduction…………………………………………………………………………………………… 15
Box A: Criteria for Evaluation of Practices …………………………………………………….. 16
Table 1: Preferred Practices and Specifications Cross-Walked to the Framework……… 1

7

Domain 1: Leadership …………………………………………………………………………….. 24
Domain 2: Integration into Management Systems and Operations ……………………….

28

Domain 3: Patient-Provider Communication ………………………………………………….. 30
Domain 4: Care Delivery and Supporting Mechanisms …………………………………….

38

Domain 5: Workforce Diversity and Training …………………………………………………. 40
Domain 6: Community Engagement …………………………………………………………… 42
Domain 7: Data Collection, Public Accountability, and Quality Improvement ………… 45

Areas Recommended for Further Research ……………………………………………………….. 50
Table 2: Areas Recommended for Further Research …………………………………………. 50

Relationship to Other NQF-Endorsed Consensus Standards ………………………………….. 51

References……………………………………………………………………………………………….. 52

National Quality Forum iii

iv National Quality Forum

National Quality Forum

Appendix A — Commissioned Paper: A Cultural Competency Framework
for Quality Measurement and Reporting ………………………………………

A-1

Appendix B — Glossary ………………………………………………………………………………

B-1

Appendix C— Implementation Examples Cross-Walked to Practices ………………………. C-1

A Comprehensive Framework and Preferred Practices
for Measuring and Reporting Cultural Competency:
A Consensus Report

Executive Summary

We envision healthcare that honors each individual patient and family, offering voice,
control, choice, skills in self-care, and total transparency, and that can and does adapt
readily to individual and family circumstances and differing cultures, languages, and
social backgrounds.

—National Priorities Partnership, 2008

FOR TOO LONG, healthcare received by minority populations has been of poorer
quality—even when factors such as access, health insurance, and income are taken into
account. Unless these inequities are addressed and care becomes more patient centered,
these disparities in health and healthcare will persist.

One major contributor to healthcare disparities is a lack of culturally competent care.
Even as healthcare systems improve, without the provision of culturally appropriate services,
medical errors, misunderstandings, and a lack of patient adherence may still increase
because of differences in language or culture. Providing culturally appropriate services not
only has the potential to reduce disparities and improve outcomes, but it also can create
greater patient satisfaction and help to increase the efficiency of clinical and support staff.

Healthcare cannot be of high quality without being delivered in a culturally competent
manner. This National Quality Forum (NQF) report, A Comprehensive Framework and
Preferred Practices for Measuring and Reporting Cultural Competency, aims to promote
culturally competent care, to reduce disparities, and to make care more patient centered.
It does so by endorsing a comprehensive framework—a road map—for measuring and
reporting cultural competency. It also endorses a set of 45 preferred practices to provide
culturally competent care.

National Quality Forum v

National Quality Forum

Overarching the framework are four guiding
principles for measuring and reporting cultural
competency. These principles are intended to
be cross-cutting and to provide broad themes
and direction that promote standardized
measurement and reporting of cultural com-
petency, drive practice improvement and
measure development in cultural competency,
and support implementation of policies and
programs to improve cultural competency:
y Cultural competency in healthcare embraces

the concept of equity, with patients having
equal access to quality care and nondiscrim-
inatory, patient-centered practices delivered
by healthcare providers.

y Cultural competency is necessary, but
not sufficient, to achieving an equitable
healthcare system.

y Cultural competency should be viewed as
an ongoing process and a multilevel
approach, with assessments and interven-
tions needed at the system, organizational,
group, community, and individual levels.
Cultural competency should not be viewed
as an endpoint; rather, communities,
organizations, and individuals should strive
for continuous improvement.

y The successful implementation of cultural
competency initiatives to achieve high-
quality, culturally competent, patient-centered
care requires an organizational commitment
with a systems approach toward cultural
competency. Addressing both organizational
and clinical aspects when managing diversity
and the needs of a diverse workforce, the
surrounding community, and the patient
population are important factors in providing
culturally competent care.

The NQF-endorsed® framework for cultural
competency establishes a conceptual model to
identify and organize preferred practices and
performance measures based on a set of seven
interrelated domains (and multiple subdomains)

that are applicable to all settings and providers
of care. Specifically, the seven primary
domains for measuring and reporting cultural
competency are:
1. Leadership. Leadership recognizes that

healthcare providers, clinical and organiza-
tional leaders, the governance board, and
the community share responsibility for and
play an essential role in the development
and implementation of cultural competency
activities, in setting policy and strategy, and
in monitoring organizational performance.
Leadership must aspire to reflect the diversity
of the community served.

2. Integration into Management Systems
and Operations. Focusing on whether
cultural competency is integrated throughout
all management and operations activities of
the organization is an essential component
of supporting the delivery of culturally
competent care.

3. Patient-Provider Communication. Clear
communication at all levels and at all times
among patients, clinicians, and support
staff is essential for effective and culturally
competent care.

4. Care Delivery and Supporting
Mechanisms. From the first encounter to the
last, care delivery structures and supporting
mechanisms—the delivery of care, the physi-
cal environment where it is delivered, and
links to supportive services and providers—
should support the provision of culturally
competent care.

5. Workforce Diversity and Training.
Ensuring workforce diversity and training
is a way to provide more effective services
for culturally diverse populations through
proactive recruitment, retention, and promo-
tion strategies. Diversity at all levels of the
organization is important. Training and
development activities should include state-
of-the-art content in cultural competency and
should reflect organizational commitment to
cultural competency.

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Framework and Preferred Practices for Measuring and Reporting Cultural Competency

6. Community Engagement. Active outreach
and the exchange of information, as well as
community inclusion and partnership in
organizational decisionmaking, help ensure
the provision of culturally competent care.

7. Data Collection, Public Accountability,
and Quality Improvement. Organizations
use these methodologies to collect the data
needed to assess their cultural competency,
to assess whether they perform routine self-
assessments in this regard, and to assess
whether they integrate cultural competency
into their public accountability and quality
improvement activities.

The framework is intended for all healthcare
organizations—health plans, hospitals, small
and large physician group practices, communi-
ty-based organizations, clinics, nursing homes,
dialysis centers, ambulatory care centers—

delivering care, including mental health
services and oral health.

Although the framework provides organiza-
tional structure for measuring and reporting the
quality of providing culturally competent care,
significant advancement in this area requires
systematic deployment of a comprehensive set
of preferred practices—and ultimately perform-
ance measures—that address the framework’s
domains. The 45 practices endorsed in this
report will improve the quality of care through
cultural competency and address the vision of
the National Priorities Partnership. They can
also serve as the basis for identification
and/or development of quality measures that
can be used for public accountability for the
delivery of culturally competent care.

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A Comprehensive Framework and Preferred Practices for Measuring
and Reporting Cultural Competency

Domain 1: Leadership
y Preferred Practice 1: Create and sustain an environment of cultural competency through estab-

lishing leadership structures and systems or embedding them into existing structures and systems.

y Preferred Practice 2: Identify and develop informed and committed champions of cultural
competency throughout the organization in order to focus efforts around providing culturally
competent care.

y Preferred Practice 3: Ensure that a commitment to culturally competent care is reflected in the
vision, goals, and mission of the organization,

and couple this with an actionable plan.

y Preferred Practice 4: Implement strategies to recruit, retain, and promote at all levels of the
organization a diverse leadership that reflects the demographic characteristics of the service
area.

y Preferred Practice 5: Ensure that the necessary fiscal and human resources, tools, skills,
and knowledge to support and improve culturally competent policies and practices in the
organization are available.

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viii National Quality Forum

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A Comprehensive Framework and Preferred Practices for Measuring
and Reporting Cultural Competency

Domain 1: Leadership (continued)
y Preferred Practice 6: Commit to cultural competency through systemwide approaches that are

articulated through written policies, practices, procedures, and programs.

y Preferred Practice 7: Actively seek strategies to improve the knowledge and skills that are
needed to address cultural competency in the organization.

Domain 2: Integration into Management Systems and Operations
y Preferred Practice 8: Integrate into the organizational strategic plan clear goals, policies,

operational procedures, and management accountability/oversight mechanisms to provide
culturally competent services.

y Preferred Practice 9: Implement language access planning in any area where care is delivered.

y Preferred Practice 10: Implement reward and recognition programs to recognize specific
individuals, initiatives, and programs within the organization that promote cultural competency.

y Preferred Practice 11: Market culturally competent services to the community to ensure that
communities that need services receive the information.

Domain 3: Patient-Provider Communication
y Preferred Practice 12: Offer and provide language access resources in the patient’s primary

written and spoken language at no cost, at all points of contact, and in a timely manner during
all hours of operation, and provide both verbal offers and written notices informing patients of
their right to receive language assistance services free of charge.

y Preferred Practice 13: Determine and document the linguistic needs of a patient or legal
guardian at first points of contact, and periodically assess them throughout the healthcare
experience.

y Preferred Practice 14: Maintain sufficient resources for communicating with patients in their
primary written and spoken languages through qualified/competent interpreter resources, such
as competent bilingual or multilingual staff, staff interpreters, contracted interpreters from outside
agencies, remote interpreting services, credentialed volunteers, and others, to ensure timely and
high-quality communication.

y Preferred Practice 15: Translate all vital documents, at a minimum, into the identified threshold
languages for the community that is eligible to be served.

y Preferred Practice 16: Translate written materials that are not considered vital when it is
determined that a printed translation is needed for effective communication.

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Framework and Preferred Practices for Measuring and Reporting Cultural Competency
A Comprehensive Framework and Preferred Practices for Measuring
and Reporting Cultural Competency

Domain 3: Patient-Provider Communication (continued)
y Preferred Practice 17: Ensure that a qualified interpreter reads a document to a patient if the

patient

cannot read the translated document.

y Preferred Practice 18: Use “teach back” as a patient engagement tool to enhance communication
between the healthcare provider and the patient during clinical encounters.

y Preferred Practice 19: Communicate key information about the proposed treatments or procedures
for which patients are being asked to provide informed consent.

y Preferred Practice 20: Regularly assess attitudes, practices, policies, and structures of all staff
as a necessary, effective, and systematic way to plan for and incorporate cultural competency
within an organization.

y Preferred Practice 21: Include family members in healthcare decisions, when requested by the
patient, when providing care for culturally diverse populations.

Domain 4: Care Delivery and Supporting Mechanisms
y Preferred Practice 22: If requested by the patient, provide resources such as provider directories

that indicate the languages providers speak, so that patients can have access

to this information.

y Preferred Practice 23: Develop and implement a comprehensive care plan that addresses cultural
concerns.

y Preferred Practice 24: Consider cultural, spiritual, and religious beliefs that may complement or
conflict

with standard medical care.

y Preferred Practice 25: Adapt the physical environment where the healthcare is being delivered
to represent the culture of the populations who access their healthcare in that environment.

y Preferred Practice 26: Use culturally appropriate care coordination services that take into
consideration the cultural diversity of the populations seeking healthcare.

y Preferred Practice 27: Explore, evaluate, and consider the use of multimedia approaches and
health information technology to enable the provision of healthcare services that are patient and
family centered and culturally tailored to the patient.

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A Comprehensive Framework and Preferred Practices for Measuring
and Reporting Cultural Competency

Domain 5: Workforce Diversity and Training
y Preferred Practice 28: Recruit and hire ethnically diverse providers and staff at all levels,

including management levels.

y Preferred Practice 29: Actively promote the retention of a culturally diverse workforce through

organizational policies and programs.

y Preferred Practice 30: Implement training that builds a workforce that is able to address the
cultural needs of patients and provide appropriate and effective services as required by federal,
state, and local laws, regulations, and organizational policies.

Domain 6: Community Engagement
y Preferred Practice 31: Engage communities to ensure that healthcare providers (individual

and organizational) are aware of current and changing patient populations and cultural and
communication needs and provide opportunities to share resources and information.

y Preferred Practice 32: Collaborate with the community to implement programs with clinical and
outreach components to address culturally diverse populations, health disparities, and equity in
the community.

y Preferred Practice 33: Utilize a variety of formal and informal mechanisms to facilitate community
and patient involvement in designing, implementing, and evaluating the effectiveness of cultural
competency activities.

y Preferred Practice 34: Healthcare professionals and organizations should engage communities in
building their assets as vehicles for improving health outcomes.

y Preferred Practice 35: Use the methodology of community-based participatory research when
conducting research in the community as a collaborative approach to research that equitably
involves all stakeholders in the research process and fosters the unique strengths that the
community brings to the process.

Domain 7: Data Collection, Public Accountability, and

Quality Improvement

y Preferred Practice 36: Utilize the Health Research & Educational Trust (HRET) Disparities Toolkit

to collect patient race/ethnicity and primary written and spoken language data from patients in
a systematic, uniform manner.

y Preferred Practice 37: Ensure that, at a minimum, data on an individual patient’s race and
ethnicity (using the Office of Management and Budget categories as modified by HRET) and
primary written and spoken language are collected in health records and integrated into the
organization’s management information systems. Periodically update the language information.

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Framework and Preferred Practices for Measuring and Reporting Cultural Competency
A Comprehensive Framework and Preferred Practices for Measuring
and Reporting Cultural Competency

Domain 7: Data Collection, Public Accountability, and Quality Improvement (continued)
y Preferred Practice 38: Utilize indirect data collection methodologies (e.g., geocoding, surname

analysis) to characterize the race, ethnicity, and primary written and spoken language of a
community for service planning and conducting community-based targeted interventions.

y Preferred Practice 39: Maintain a current demographic, cultural, and epidemiological profile
of the community to accurately plan for and implement services that respond to the cultural
characteristics of the service area.

y Preferred Practice 40: Apply a quality improvement framework to improve cultural competency
and discover and eliminate disparities in care using the race, ethnicity, and primary written and
spoken language information collected by the institution.

y Preferred Practice 41: Publicly report data for the applicable NQF-endorsed disparities-sensitive
national voluntary consensus standards for ambulatory care stratified by race/ethnicity and
primary written and spoken language.

y Preferred Practice 42: Regularly make available to the public information about progress and
successful innovations in implementing culturally competent programs (especially the NQF-
endorsed preferred practices for cultural competency), and provide public notice in communities
about the availability of this information.

y Preferred Practice 43: Assess and improve patient- and family-centered communication on an
ongoing basis.

y Preferred Practice 44: Any surveys created by or conducted by the organization must collect
race, ethnicity, and primary written and spoken language, and analysis and results must be
stratified by race, ethnicity, and primary written and spoken language.

y Preferred Practice 45: Ensure that conflict and grievance resolution processes are culturally
sensitive and capable of identifying, preventing, and promptly and equitably resolving
cross-cultural conflicts or complaints by patients or between organizational staff.

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A Comprehensive Framework and Preferred Practices
for Measuring and Reporting Cultural Competency:
A Consensus Report

Framework for Measuring and
Reporting Cultural Competency

Introduction
RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE are well documented and
indicate that minorities disproportionately suffer from higher rates of disease and death and
tend to receive a lower quality of care even when factors such as access, health insurance,
and income are taken into account.1 The Institute of Medicine (IOM) addressed this issue in
its report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care and
noted that one major contributor to disparities in health and healthcare is a lack of culturally
competent care.2 Providing culturally appropriate services has the potential to not only
reduce disparities and improve outcomes, but it also can help to increase the efficiency of
clinical and support staff as well as create greater satisfaction among patients.

3

Efforts to define and classify cultural competency are ongoing. In 2001, the Department
of Health and Human Services (DHHS) Office of Minority Health published standards for
culturally and linguistically appropriate services (CLAS) for healthcare organizations.4 These
standards were an initial effort to provide structure to what constitutes culturally appropriate
healthcare services: The National Committee for Quality Assurance (NCQA) now has an
awards program for health plans that demonstrate innovative approaches in meeting
CLAS standards. In addition, policy level approaches for cultural competency have been
introduced by The Joint Commission and the Centers for Medicare & Medicaid Services.
The Joint Commission has a project to develop hospital accreditation standards to promote,
facilitate, and incentivize the provision of culturally competent, patient-centered care, and
NCQA has been working to develop a module of standards suitable for evaluating efforts
to improve the provision of culturally and linguistically appropriate services and to identify
and reduce care deficiencies.

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Developing culturally competent healthcare
systems is an integral and vital component in
reducing disparities and delivering patient-
centered care. Moreover, even as healthcare
systems improve, without the provision of
culturally accurate and appropriate services,
medical errors, misunderstandings, and a lack
of patient adherence may still increase because
of differences in language or culture. This
project aims to promote culturally competent
care and to reduce disparities by endorsing
a comprehensive framework for measuring
and reporting cultural competency and by
endorsing preferred practices to provide
culturally competent care. As is true for all
National Quality Forum (NQF)-endorsed®

products, the framework and practices
presented in this report will be reviewed
and revised as the evidence base and field
of cultural competency evolve.

Purpose
The purpose of this project was to:

y endorse a comprehensive national frame-
work for evaluating cultural competency
across all healthcare settings;

y endorse a minimum set of preferred
practices for cultural competency based
on the framework. These practices are
both specific and overarching—that is,
they cover all settings and providers; and

y identify high-priority research areas to
advance the evaluation of cultural
competency and its impact on care.

Defining Cultural Competency
Over the past decade, cultural competency
has had a range of meanings.5 For the purposes
of this project, NQF’s definition of cultural
competency is intended to address both its
individual and organizational aspects, as well
as its structural and process elements:

Cultural competency is the ongoing capacity
of healthcare systems, organizations, and
professionals to provide for diverse patient i

populations high-quality care that is safe,
patient and family centered, evidence
based, and equitable.

Healthcare cannot be of high quality with-
out being delivered in a culturally competent
manner.ii In 2001, IOM’s report Crossing the
Quality Chasm: A New Health System for the
21st Century outlined six aims for the quality
of healthcare—that it should be safe, effective,
patient centered, timely, efficient, and equi-
table.6 High-quality care is state-of-the-art care
that is grounded in evidence-based clinical
practices. According to IOM’s7 equity aim for
health system improvement, the quality of care
a patient receives should not differ because
of characteristics such as gender, race, age,
ethnicity, income, education, disability, sexual
orientation, or location of residence. However,
although the quality of the care should not
differ, the care is patient centered only when
clinicians treat and respect each patient as
an individual, within the context of his or her
care.8,9 This requires a partnership among
clinicians, patients, and families to ensure that

i The term patient refers to the individual recipient of care—that is, patient, client, legal surrogate, or person.
ii High-quality healthcare is delivered in a safe, effective, patient-centered, timely, efficient, and equitable manner and is
state of the art and evidence based.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

healthcare decisions take into account patient
preferences. In order to be patient centered,
evidence based, and equitable, culturally
competent healthcare requires oral and written
language access, sensitivity to cultural differ-
ences, and attention to patients’ health literacy
needs. The delivery of culturally competent
care should not focus on one specific clinical
encounter, but rather should relate to the health
and illness problems experienced by individuals
and their families across their life span.

Cultural competency is achieved through the
implementation and use of policies, learning
processes, and structures by which organiza-
tions and individuals develop and support the
attitudes, behaviors, practices, and systems
that are needed for effective cross-cultural
interactions. Factors that can effect cross-cultural
interactions include but are not limited to
sociocultural factors such as race/ethnicity,
nationality, language, health literacy, gender,
socioeconomic status (SES), immigrant status
(age at immigration and length of time in the
United States), physical and mental ability,
mental health, sexual orientation and gender
identity, religion, age, and occupation.10

These factors can be conceptualized as cultural
group identities. Individuals’ affiliations to
cultural groups are complex, with individual
differences based on the group identity profile
and strength of the group identities.11 For
example, a second-generation Hispanic patient
of higher SES may have a different cultural
reference point than a recent Hispanic immi-
grant of lower SES. That is, the group identity
profile, as well as the strength of group identi-
ties, is likely to differ, and these differences may
affect an individual’s interactions with the
healthcare system.

It is important to note that children’s cultural
experiences and identities can be and are
frequently different from those of their parents.12

For the most part, there are no substantial
differences between adults and children with
respect to receiving culturally competent care
that pertain to the preferred practices presented
in this report, and the use of the terms “patients”
and “patients and families” includes children.
Nonetheless, children are a distinct population
that may have divergent needs from those of
their parents. For example, a child raised in
the United States may have a very different cul-
tural experience from his or her first-generation
immigrant family. In infancy and early child-
hood a child’s culture will be more reflective
of his or her family, and the clinical encounter
will generally be addressed to the caregiver
alone. As the child grows into middle and late
childhood, however, he or she is exposed to
beliefs, values, cultural practices, and lan-
guages that are different from those that the
parents experienced. The clinical encounter
will gradually transition to include the child,
and, by late adolescence, it will be focused
on the adolescent alone. This is a complex
transition not only because of the autonomy
issues of the increasingly independent adoles-
cent, but also because the child is likely to
have health beliefs that differ from those of
the family. Thus, in the pediatric population,
communication must be family centered
and child centered in a developmentally
appropriate manner.

Additionally, NQF recognizes that individuals
with physical, cognitive, or emotional disabilities
experience many of the same barriers to high-
quality, safe care as do those who have limited
English proficiency (LEP) or those who are from

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other cultural backgrounds. Groups that share
a particular disability—such as limitations in
sight, hearing, speech, or mobility—often
share a unique culture among themselves, such
that communication and cultural differences
are also sources of barriers to their healthcare.
The identification of preferred practices to
reduce or eliminate these barriers was beyond
the scope of this project. However, the project’s
Steering Committee strongly recommended
that an additional report to address these
barriers be developed under the guidance
of a new, appropriately constituted Steering
Committee that represents the knowledge and
experience needed to address cultural barriers
resulting from physical, cognitive, or emotional
disabilities.

Identifying the Framework
A Steering Committee guided the development
of an evidence-based framework,iii relying on
a paper commissioned for NQF, “A Cultural
Competency Framework for Quality
Measurement and Reporting” (Appendix A).

Purpose of the Framework
Despite research efforts to build an evidence
base for cultural competency that would result
in improved health outcomes and decreased
system costs, there is a noticeable absence of
a broadly defined framework, logic model, or

definition that would move the field beyond
race- or ethnic-specific interventions.13 A
nationally endorsed framework around cultural
competency can serve as a road map for the
identification of a set of preferred practices
and performance measures, as well as for the
identification of areas requiring additional
research or development. The evidence-based
framework establishes a conceptual model to
identify and organize NQF-endorsed preferred
practices and performance measures based on
a set of interrelated domains and subdomains
that are applicable to multiple settings of care
and providers of care. The framework also
serves as the basis to assess what is currently
available and to identify areas where gaps in
practices exist. Guided by the framework, a
set of preferred practices, which are presented
in this report, and measures, which will be
endorsed based on this work, should provide
comprehensive evaluation and reporting tools
to ensure that care is delivered in a culturally
competent manner.

The framework is intended to be comprehen-
sive and applicable to all healthcare settings
and all providers of healthcare, as are the
45 preferred practices that comport to the
framework. Although some of the specifications
may be more easily implemented within larger
healthcare facilities or large physician group
practices than in smaller settings, they can be
adapted to also work, for example, in a single
physician’s office, a small rural hospital,

iii This framework is intended for all healthcare organizations (health plans, hospitals, small and large physician group
practices, community-based organizations, clinics, nursing homes, dialysis centers, ambulatory care centers) delivering
care, including mental health services and oral health. Its audience is all employees of those organizations. For the
purposes of this framework, healthcare professionals are defined as physicians, administrators, nurses, physical and
occupational therapists, linguistic services providers, psychologist social workers, and others who provide care to a
patient.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

nursing homes, or home health agencies.
The expectation is that individual offices and
organizations will prioritize and implement the
framework, and, in particular, the practices,
as best suited for their short- and long-term
needs. Additionally, NQF notes that the public
health community plays an important role in
delivering culturally competent care. However,
although many of the framework domains
and subdomains, principles, and practices
are applicable to the public health community,
the scope of this project is focused on the
healthcare delivery system.

Guiding Principles
Guiding principles for measuring and report-
ing cultural competency provide broad themes
and direction that, if uniformly adopted by all
stakeholders, promote standardized measure-
ment and reporting, drive practice improvement
and measure development, and support imple-
mentation. The guiding principles are intended
to be overarching and/or cross-cutting across
all (or multiple) domains of the framework
presented below.

The four guiding principles are as follows:

Principle 1.
Cultural competency in healthcare embraces
the concept of equity, with patients having
equal access to quality care and nondiscrimi-
natory, patient-centered practices delivered by
healthcare providers.

Principle 2.
Cultural competency is necessary, but not
sufficient, to achieving an equitable healthcare
system.

Principle 3.
Cultural competency should be viewed as an
ongoing process and a multilevel approach,
with assessments and interventions needed at
the system, organizational, group, community,
and individual levels.14,15 Cultural competency
should not be viewed as an endpoint; rather,
communities, organizations, and individuals
should strive for continuous improvement.16

Principle 4.
The successful implementation of cultural
competency initiatives to achieve high-quality,
culturally competent, patient-centered care
requires an organizational commitment
and a systems approach toward cultural
competency.17,18,19 Addressing both organiza-
tional and clinical aspects when managing
diversity and the needs of a diverse workforce,
the surrounding community, and the patient
population are important factors in providing
culturally competent care.

20

Framework Domains and Subdomains
Standardizing the measurement and reporting
of cultural competency requires the identifica-
tion of a comprehensive framework that delin-
eates the domains of high-quality, culturally
competent care. From this framework, pre-
ferred practices can be identified—and from
those practices, measures can be developed.
Gaps in practices (or measures) should be
readily identifiable based on this approach.

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The seven primary domains of measuring and
reporting cultural competency are as follows:

1. Leadership
2. Integration into Management Systems and

Operations

3. Patient-Provider Communication

4. Care Delivery and Supporting Mechanisms

5. Workforce Diversity and Training

6. Community Engagement

7. Data Collection, Public Accountability, and

Quality Improvement

Each domain includes subdomains that
further delineate the components. Although the
subdomains are included among distinctive
domains, many of them are cross-cutting and
could be applicable in other domains.

DOMAIN 1
Leadership.iv Leadership recognizes that
healthcare providers, clinical and organiza-
tional leaders, the governance board, and the
community share responsibility for and play an
essential role in the development and imple-
mentation of cultural competency activities, in
setting policy and strategy, and in monitoring
organizational performance. Leadership must
aspire to reflect the diversity of the community
served.

Subdomain 1.1
Organizational Culture. Organizational
culture should be inclusive and should value
cultural differences. Being inclusive signifies that
the organization’s decisionmaking processes
include diverse points of views from both
within and outside the organization. When
an organization values diversity, that diversity
is demonstrated in its practices, structure, and

policies. The leaders of an organization are
instrumental in setting organizational culture.21

Subdomain 1.2
Commitment to Serving a Diverse
Population. Cultural competency activities
are most effective when the organization’s
top management, governance boards,
executives, and policymakers embrace cultural
competency and diversity and communicate
this support throughout the organization and
the community.22,23

Subdomain 1.3
Leadership Diversity. Leadership at all levels
of the organization, including clinical and
administrative leaders and the governance
board, reflects the community.24 Diversity is
critical at the department chief and chair
levels. Leadership diversity increases the likeli-
hood that the needs of a diverse workforce
and patient population are taken into account
in organizational decisionmaking processes.

25

However, minorities have traditionally faced
barriers, or a “glass ceiling” effect, that have
excluded them from upper management
positions.26 As such, healthcare organizations
need to adopt and use proactive human
resource strategies aimed at diversifying the
leadership ranks.

Subdomain 1.4
Dedicated Staff and Resources. An organi-
zation demonstrates its commitment to cultural
competency by dedicating resources and
designating staff for activities that promote
cultural competency. Dedicated resources
can be shown by budgeting them for cultural
competency activities.27,28,29 Dedicated staff
can include an executive-level staff member, a
department, or an office that focuses on multi-
cultural and/or linguistic issues. This can be

iv This domain refers to leadership by the board of directors, trustees, and C-suite level and senior managers.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

instrumental in coordinating organization-wide
initiatives and monitoring progress toward
cultural competency goals.30,

31

Subdomain 1.5
Policies. Formal policies are needed that
address cultural competency issues, such as the
recruitment and retention of a diverse work-
force and the provision of language services
and training and development.32,33 Policies
“express an organization’s intentions and pro-
vide a blueprint for action.” 34 These internal
policies should be in conformity with external
regulatory and statutory policies.

35

Subdomain 1.6
Training and Development. The training and
development of leaders and staff on cultural
competency issues is needed at all levels of
the organization, including the governance
board.36 Leadership participation in training
and development sends a signal to organiza-
tion members about its commitment to cultural
competency. (See also Domain 5: Workforce
Diversity and Training.)

DOMAIN 2
Integration into Management Systems and
Operations. Focusing on whether cultural
competency is integrated throughout all
management and operations activities of the
organization is an essential component of
supporting the delivery of culturally competent
care.

Subdomain 2.1
Strategic Planning. The strategic planning
process includes environmental scanning,
asset assessment, and needs assessment of
the communities served and the formulation
of goals related to cultural competency.37
Strategic goals reflect the organization’s
priorities for resource use and deployment.

Subdomain 2.2
Service Planning. Organizations should
design services that take into account the
needs of the patient populations they serve.
This includes all elements of the healthcare
encounter, including the greeting of patients,
referrals to other services, admission to
discharge planning, and encounters with
support staff, with the ultimate goal of
improving access to care for all patients38
(e.g., providing child care or transportation
services; expanding operating and clinical
hours to accommodate community work
patterns; adapting to ethnic or religious dietary
preferences; and allowing for large families
visiting or staying with hospitalized
patients).39,40

Subdomain 2.3
Performance Evaluation. Job descriptions
and performance evaluation systems should
include criteria related to cultural competen-
cy,41,42 and the performance evaluation
process should include a survey of patient and
family experience with care. This results in
accountability for meeting cultural competency
goals. (See also Domain 7: Data Collection,
Public Accountability, and Quality
Improvement.)

Subdomain 2.4
Reward Systems. Managers and staff should
be rewarded for meeting cultural competency
goals.43 Incentives help align the goals of an
organization’s members with those of the
organization: Behavior or performance that is
positively reinforced tends to be repeated.44

Subdomain 2.5
Marketing and Public Relations.
Organizations promote and market their
services through a variety of media that reach
out to diverse populations. These media
include ethnic newspapers, television news

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programs, and radio stations.45 Marketing
and social marketing also should emphasize
the types of services offered, such as those
involving interpretation and translation, as well
as other cultural services. Performance and
quality information should be publicly reported,
should include patient experience with care,
and should be presented in a format that can
be easily understood by the community.
Organizations should participate in efforts that
raise public awareness of cultural competency
activities and document the progress that is
being made in meeting goals,46,47 which can
include, for example, producing a statistical
annual report on patient demographics, inter-
preter use, and availability; making translated
materials available; and documenting progress
being made in cultural competency training.
Such reports also could include patient
evaluations of services and providers. These
approaches can serve as marketing tools,
while also enhancing an organization’s image
among diverse communities.

DOMAIN 3
Patient-Provider Communication. Clear
communication at all levels and at all times
among patients, clinicians, and support staff is
essential for effective and culturally competent
care.

Subdomain 3.1
Language Access. Language access services
are imperative to increase access to care;
improve quality of care, patient satisfaction,
health outcomes, and health status; and
enhance or ensure appropriate resource
utilization.48 High-quality language access
services are needed at all points of patient
contact to improve provider and staff communi-
cation with LEP patients. Communication that

is accurate and understandable increases
the likelihood of the provision of appropriate
care, as well as patient safety and patient
adherence.49,50,51

Subdomain 3.2
Interpreter Services. High-quality interpreter
services are imperative for patients to increase
the likelihood that they receive appropriate
care.52,53,54,55 An organization should first strive
to employ bilingual staff and providers. The
bilingual proficiency of staff and providers
needs to be assessed, however, to ensure that
they speak the additional language(s) at a
level such that high-quality services can be
provided.56 Having certified interpretersv,57
available for every point of contact may not
be an achievable goal, but, at minimum,
professionally trained and competent
interpreters should be employed “whose
sole function in the healthcare setting is to
interpret,”58 because they clearly have been
shown to be effective compared with ad
hoc interpreters.59,60,61 Professional interpreter
services may be in person or remote; remote
interpreter services include telephone language
lines, video links, and other remote systems.
Health professionals and other staff members
need to be trained on how to work with
interpreter services and how to determine
whether an individual is competent to interpret.

Subdomain 3.3
Translation Services. Patient-related written
materials should be translated into the most
common languages of the patient popula-
tion62,63 and should be evaluated for context,
be written from the patient’s perspective, and,
when possible, be originally written in the
intended language. Relevant patient-related
materials include applications, consent forms

v When evaluating the quality of interpreter services, it is important to consider that the work of the National Coalition
for Healthcare Interpreter Certification is still ongoing, and a process for certification for all languages has not yet
been established.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

(procedural consent, research consent),
participation in therapeutic trial forms,
preventive and treatment instructions, and
patient education materials. Translated
materials should be evaluated for linguistic
and cultural appropriateness with respect to
both content and context.64

Subdomain 3.4
Health Literacy Strategies. Addressing the
literacy needs of patients using both oral and
written communication can be an issue even
if the patient’s primary written and spoken
languagevi is English. Healthy People 2010
defines health literacy as the “degree to which
individuals can obtain, process, and under-
stand the basic health information and services
they need to make appropriate health deci-
sions.”65 People with low health literacy tend
to have more problems with both written and
oral communication.66 Strategies to improve
oral and written communication with low-
literacy patients could include the following:
1) avoid the use of medical jargon, and
instead use commonly understood words;
2) use audiovisual and graphic aids to supple-
ment oral and written instructions; 3) include
interactive instructions by making patients do,
write, say, or show something to demonstrate
their understanding; 4) write materials at or
below the 5th-grade level; 5) pretest materials
to evaluate whether they are suitable for the
intended audience; and 6) utilize the NQF-
endorsed safe practice “teach back” method
to ask each patient to teach back in her or his
own words key information about the proposed
treatments or procedures for which he or she is
being asked to provide informed consent.67,68,6

9

Subdomain 3.5
Knowledge of Culture and Social Context.
Healthcare providers should have pertinent
information about the cultural groups being
served with respect to traditional healing
practices; health-related beliefs and cultural
values; disease incidence, prevalence, and
outcomes; and health disparities.70,71,72,73 This
should include knowledge of the sociodemo-
graphics, migration history, and other relevant
socioeconomic characteristics of members of
the local communities receiving care. (See also
Domain 4: Care Delivery and Supporting
Mechanisms, Subdomain 4.1: Clinical
Encounter.)

Subdomain 3.6
Cultural Awareness. Self-examination and
the exploration of one’s own personal and
organizational cultural background are essen-
tial to optimum patient-provider communication.
This includes being cognizant, observant, and
conscious of similarities and differences among
cultural groups.74 It also includes having an
awareness of one’s own assumptions, biases,
stereotypes, and prejudices with respect to
individuals from other cultures.75,76,77 (See also
Domain 4: Care Delivery and Supporting
Mechanisms, Subdomain 4.1: Clinical
Encounter.)

Subdomain 3.7
Cross-Cultural Communication Skills.
Skills that are used to obtain culturally relevant
data, such as through conducting cultural
assessments and culturally based physical
assessments, are a necessary component of
this subdomain.78,79,80,81 Patient-based cross-
cultural communication makes the patient a
primary source of cultural knowledge and an
active participant in patient-clinician discus-
sions.82 The appropriate skills are needed to

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vi “Primary written and spoken language” is defined as the self-selected language the patient wants to use to communicate
with her or his healthcare provider.

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identify and negotiate different styles of com-
munication, different decisionmaking prefer-
ences and family roles, and sexual and gender
issues. In addition, skills are needed to identify
issues involving mistrust, prejudice, and racism;
religion and spirituality; disability; and sexual
orientation.83 Communicating effectively with
different people is a process that requires trust,
awareness, sensitivity, respect, and honesty.

Subdomain 3.8
Family Centeredness. Patient-provider
communication also means respecting the
wishes of members of culturally diverse groups
and including family members in healthcare
decisionmaking.84 Organizational procedures
and policies should be adapted within existing
privacy regulations and laws and should
accommodate family-centered care as deter-
mined by the patient. (For example, patients
may have difficulty explicitly “asking” a
provider to include their families in decision-
making, but their actions may signal that they
desire to do so.) Understanding the role that
the family plays in healthcare decisions is
integral to delivering family-centered care.
This includes having knowledge of culturally
defined composition and roles within families
and having the skills needed to communicate
with family members, with attention paid to
age, gender, and more. This knowledge
enables caregivers to assist family members
in decisionmaking, when requested; honor
patient and family perspectives and choices;
and ensure that patient and family knowledge,
values, beliefs, and cultural backgrounds are
incorporated into the planning and delivery
of care.

DOMAIN 4
Care Delivery and Supporting Mechanisms.
From the first encounter to the last, care deliv-
ery structures and supporting mechanisms—
the delivery of care, the physical environment
where it is delivered, and links to supportive

services and providers—should support the
provision of culturally competent care.

Subdomain 4.1
Clinical Encounter. Both patients and health-
care providers bring to the healthcare
encounter their own cultural backgrounds,
beliefs, practices, and languages—all of which
can affect interactions.85 In certain instances,
patients and providers could have different
understandings of what constitutes appropriate
care and what their roles should be in the
encounter. Also, the culture or beliefs of some
patients may mean they are less likely to ask
questions, question the provider’s care plan,
or share in decisionmaking.

Subdomain 4.2
Physical Environment. The physical environ-
ment should include culturally sensitive design,
architecture, and physical environments, where
the décor, artwork, posters, and literature
reflect the diversity of the area being served.86
The environment also should include appropri-
ate signage in the major languages spoken.87

Subdomain 4.3
Assessment Tools. Tools, such as environ-
mental scans, help elicit culturally relevant
information on health beliefs, values, behaviors,
and practices.88 These data can be used to
assist with establishing a physical environment,
care delivery, and supporting mechanisms that
are culturally appropriate for the community
served.

Subdomain 4.4
Coordination of Care. Documenting and
tracking referrals to other healthcare services
across the continuum of care and ensuring that
information about patients’ cultural needs is
shared with other healthcare providers are
important components of delivering culturally
competent care. Coordination of care also
includes providing assistance with palliative

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

and end-of-life care and helping patients navi-
gate the healthcare system. Care transitions
back to home and family, disease management,
and medication reconciliation are critical areas
that require culturally competent coordination
of care.

Subdomain 4.5
Linkages with Community- and Faith-Based
Organizations. Understanding and addressing
the context of the patient (e.g., SES, supports/
stressors, environmental hazards) are essential
elements of cultural competency.89,90 It also is
important to identify community- and faith-
based organizations, such as human, social
service advocacy, civic, neighborhood, and
religious organizations, and coordinate with
them to assist with care delivery.

Subdomain 4.6
Linkages with Alternative Medicine
Providers. Creating these linkages involves
identifying patients’ use of alternative providers
and complementary and integrative healing
modalities. It also involves coordinating with
these providers to augment allopathic treatments
and avoid any complications that may result
from the use of incompatible therapies.91

Subdomain 4.7
Health Information Technology. New
information technologies, such as electronic
and personal medical records, should be
used to enhance and promote the delivery of
culturally competent care.

DOMAIN 5
Workforce Diversity and Training. Ensuring
workforce diversity and training is a way to
provide more effective services for culturally
diverse populations through proactive recruit-
ment, retention, and promotion strategies.
Diversity at all levels of the organization is

important. Training and development activities
should include state-of-the-art content in cultural
competency and should reflect organizational
commitment to cultural competency.92

Subdomain 5.1
Recruitment and Retention. Human resource
practices should be aimed at diversifying the
workforce at all levels of the organization.93
Racial/ethnic and language concordance
between patient and provider has been associ-
ated with better patient experiences with care
and satisfaction.94,95 However, the current
demographics of the health professions do not
correspond to the composition of the general
workforce. For example, although African
Americans and Hispanics account for about
25 percent of the workforce, fewer than
12 percent of physicians and therapists and
only 15 percent of registered nurses are from
these two racial/ethnic groups.96 Needed are
proactive recruitment strategies that will result in
a more diverse applicant pool. Organizations
should seek alternatives to generic newspaper
advertisements, search firms, and other con-
ventional and mainstream recruiting methods.
Community-based and national organizations
and networks and publications and/or search
firms that target diverse populations may
provide better channels for recruiting and for
advertising vacancies.97 Historically Black
Colleges and Universities, predominately
Hispanic/Latino colleges and universities, and
healthcare associations representing diverse
individuals are also valuable resources.

Furthermore, organizational efforts aimed at
improving the diversity of the workforce pipeline
are needed. This may include partnerships
with local elementary and secondary schools,
particularly those with a high percentage of
racial/ethnic minorities, to increase students’
interest in the healthcare professions.
Organizational efforts need to go beyond
recruitment strategies and include retention
strategies—otherwise organizations can become

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a “revolving door” for diverse employees, as
they leave the organization in pursuit of better
opportunities or a more welcoming environment.
Retention strategies include efforts to create a
welcoming climate for diverse populations,
identify barriers that prevent employees from
achieving their full potential, and provide pro-
motion opportunities.98,99 Programs for formal
mentoring, leadership development, profession-
al development and training, work-life balance
and flexible benefits, and affinity groups are
among the human resource retention strategies
that can be used.100

Subdomain 5.2
Training Commitment and Content. Ensuring
that managers and staff at all levels of an
organization receive appropriate and ongoing
training in cultural competency is essential—
and these efforts must be evaluated.101,102
Training should include strategies to assist
diverse staff members improve how they relate
to one another. Staff training should emphasize
the knowledge and skills outlined under the
patient-provider communication and care
delivery and supporting mechanism
domains.103,104 Leadership training should
include content from all seven of the NQF-
endorsed domains of cultural competency.
Cultural competency training can be delivered
as a stand-alone program, or it can be inte-
grated into other training programs. Formal
training can be complemented with less formal
activities that develop staff knowledge about
the cultures and languages of their patients,
such as cultural fairs and reading clubs focused
on specific cultures or languages.105 This train-
ing should be conducted by qualified staff who
are trained and expert in cultural competency,
and the training should be periodically updated,
repeated, and assessed for effectiveness and
relevance, so that it reflects the populations
served by the organization and its staff.

DOMAIN 6
Community Engagement. Active outreach
and the exchange of information, as well
as community inclusion and partnership in
organizational decisionmaking, help ensure
the provision of culturally competent care.

Subdomain 6.1
Community Outreach. Engaging with com-
munities means conducting active outreach that
includes collaborative relationships and part-
nerships with entities to help understand and
address the cultural needs of the communities
served.106 It also may include liaisons with
others in the community through community
health workers or by having members of
minority communities reach out to their
communities.107,108 For example, community
health workers who are trained to teach others
with the same chronic conditions about disease
self-management can be important resources.

Subdomain 6.2
Community Representation in Organizational
Decisionmaking. The use of formal and
informal mechanisms for community engage-
ment, such as community advisory groups or
committees for service planning and implemen-
tation, helps ensure community representation
in organizational decisionmaking.109,110 Such
mechanisms also are important to incorporate
community involvement into quality improve-
ment activities.1

11

Subdomain 6.3
Community Investments. Community invest-
ment involves investing in both the infrastructure
and human capital of communities, as well
as taking advantage of other community assets
for outreach and educational and information-
gathering activities.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

Subdomain 6.4
Community-Based Participatory Research
(CBPR).vii Actively engaging in CBPR can
bring tremendous benefits. Trained community
advocates can educate and inform the com-
munity about clinical trials and the need for
diversity. To establish trust, the community and
community advocates should be engaged
before research is proposed and developed.
Community advocates should be engaged,
when possible, in identifying the relevance of
research for members of the community and in
its design and planning, and should provide
feedback on how to meet community members’
needs.

DOMAIN 7
Data Collection, Public Accountability, and
Quality Improvement. Organizations use
these methodologies to collect the data needed
to assess their cultural competency, to assess
whether they perform routine self-assessments
in this regard, and to assess whether they
integrate cultural competency into their public
accountability and quality improvement
activities.

Subdomain 7.1
Collection of Patient Cultural Competency-
Related Information. Various mechanisms are
used to collect data on cultural subgroups—
such as race/ethnicity; country of origin;
length of stay in the United States; and lan-
guage preferences, education, and income of
patients—and to integrate the data into infor-
mation systems.112,113 These data are important
for strategic and service planning and can be
used to monitor healthcare disparities and for

quality improvement.114 The Joint Commission
now requires the recording of patients’ lan-
guage and communication needs in the patient
record.115 Although this information is impera-
tive to quality improvement, it also should be
integrated into public reporting initiatives.

Subdomain 7.2
Collection of Community Cultural
Competency-Related Information. Collection
of this information includes maintaining current
demographic, cultural, socioeconomic, and
epidemiological profiles and needs assessments
of the communities served and using the data
for strategic planning, quality improvement,
and public reporting initiatives.116,117,1

18

Subdomain 7.3
Quality Improvement. Organizations integrate
cultural competency into their internal quality
improvement activities. Quality improvement
can be viewed as an organization-wide
approach to the planning and implementation
of continuous improvement in performance.
As such, quality improvement emphasizes con-
tinuous internal examination and improvement
of work processes by teams of staff trained in
basic statistical techniques and problem-solving
tools and empowered to make decisions based
on the analysis of the data.119 Healthcare
organizations should use quality improvement
activities to address health disparities in access,
outcomes, or patient experiences with care.

Subdomain 7.4
Accountability. Information about cultural
competency and healthcare quality is impera-
tive to help make the healthcare system more

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13

vii Community-based participatory research (CBPR) is a collaborative approach to research that combines methods of
inquiry with community capacity-building strategies to bridge the gap between knowledge produced through research
and what is practiced in communities to improve health. Interest is growing rapidly among academic institutions, health
agencies, and communities in forming research partnerships; however, few guidelines are available that describe how to
develop or evaluate CBPR proposals or what resources are required to promote successful collaborative research efforts.
See Viswanathan M, Ammerman A, Eng E, et al., Community-Based Participatory Research: Assessing the Evidence.
Evidence Report, Technology Assessment No. 99, Rockville, MD: Agency for Healthcare Research and Quality (AHRQ);
2004. AHRQ Publication 04-E022-2.

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accountable, to improve patient and family
understanding and decisionmaking, and to
improve quality. Public reporting of quality
data is widespread120,121 and will continue
to increase, as will pay-for-reporting and
pay-for-performance initiatives by the federal
government, states, and private payers.
However, the degree to which patients and
families are actually using this information to
make decisions about their healthcare is
mixed.122,123,124

Subdomain 7.5
Assessment of Patient Experiences with
Care. Patient experiences with care should
be assessed in a patient’s own language
using qualitative and quantitative methods;
this information should be reported publicly
using the NQF-endorsed Hospital Consumer
Assessment of Health Plans (HCAHPS),
Ambulatory CAHPS (ACAHPS), and End-Stage
Renal Disease CAHPS. Patient assessments of
care are critical, because they capture first-
hand experiences as patients interact with the
healthcare system. The CAHPS® family is a
set of standardized survey instruments that
assess patient experiences with care in various
provider settings. Earlier research using CAHPS
data documents racial/ethnic and language
differences in patients’ experiences with
care.125,126,127 Focus groups and personal
interviews are qualitative methods that can
complement such quantitative assessments
by providing more in-depth information on
the observed cultural differences in patient
experiences with care.

Subdomain 7.6
Performance Management Systems. Cultural
competency-related measures, such as balanced
score cards, organizational climate surveys,
adverse events reports, and outcome-based
evaluations, should be included in organiza-
tional performance management systems.128,1

29

Including these measures in performance man-
agement systems elevates their importance in
the organization.130 Examples of metrics that

can be incorporated are patient and human
resource outcomes for different cultural groups.

Subdomain 7.7
Self-Assessments of Cultural Competency.
Ongoing self-assessments of an organization’s
progress in meeting its own cultural competency
strategic plan131 are needed at all four levels
of care: system, organization, group, and
individual.132 System- and organization-level
assessments provide a picture of the organiza-
tion’s readiness for cultural competency by
examining its structures, policies, and practices.
Individual-level assessments of cultural compe-
tency should be used, as should group-level
assessments, which can provide a gauge of
organizational culture and climate. Community
assessments can provide information that can
help organizations adapt to the diversity
and cultural contexts of the individuals and
communities served.133

Subdomain 7.8
Documentation of Cultural Competency
Practices. Mechanisms should be used to doc-
ument that culturally competent care services
have been delivered, such as the provision of
language services, the presence of workforce
diversity, the provision of referrals to alterna-
tive medicine providers and community-based
organizations, and compliance with NQF-
endorsed preferred practices. This information
is important for ongoing self-assessments of
cultural competency, as well as for public
reporting of such activities.

Subdomain 7.9
Documentation of Cross-Cultural Complaints
and Resolutions. Having mechanisms in place
to identify, document, and resolve cross-cultural
conflicts or complaints by patients is important
in the provision of culturally competent care.134
Individuals from diverse backgrounds are more
vulnerable to having experiences during which
their cultural differences are not accommodat-
ed or respected by healthcare organizations.
Some of the mechanisms that organizations
can adopt to identify, document, and resolve

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

cross-cultural conflicts include providing cultural
competency training to staff who handle com-
plaints and grievances or other legal or ethical
conflict issues; providing notice in other lan-
guages about the right of each patient to file a
complaint or grievance; providing the contact
name and number of the individual responsible
for the disposition of a grievance; and offering
ombudsperson services.135

Preferred Practices for
Measuring and Reporting
Cultural Competency
Introduction
The need for preferred practices in cultural
competency for measurement and reporting is
urgent. Many organizations and government
agencies are currently working to advance
the field and assist healthcare providers with
providing culturally competent care. However,
there is no consensus regarding the following
central questions: 1) What constitutes culturally
competent care? 2) Who is accountable to
ensure it is delivered? 3) How do health systems
and providers measure cultural competency?
and 4) Does culturally competent healthcare
lead to improved health outcomes? Without
national voluntary consensus standards for
culturally competent care, the important work
that is currently being conducted will remain
unconnected. To push the field forward, all
stakeholders must rally around common
preferred practices. Nationally endorsed
consensus standards for culturally appropriate
care can serve as a road map for the identifi-
cation of a set of preferred practices and per-
formance measures and can be used to help
identify areas requiring additional research or

development. In addition, the practices will
provide a structured perspective for evaluating
the development, expansion, and modifications
of new and existing programs (and their
assessments) for cultural competency.

Cultural competency should occur across the
full spectrum of healthcare delivery and should
involve multiple providers, organizational
staff—including leadership—and all settings
of care. The purpose of preferred practices
for, and ultimately, measures of, cultural
competency are to:

y improve the quality of care through cultural
competency and therefore achieve positive
patient outcomes through care that is safe,
patient and family centered, evidence
based, and equitable;

y provide guidance for all stakeholders by
identifying the domains and subdomains
that can be used in making decisions about
the delivery of culturally competent care; and

y serve as the basis for quality measures, or
the development of quality measures, that
can be used for public accountability.

Because measures do not exist to address
comprehensive cultural competency, the NQF
set of evidence-based preferred practices can
serve as the building blocks for promoting
high-quality, culturally competent care across
all practice settings and can serve as the basis
for developing performance measures.

NQF has endorsed a set of 45 preferred
practices that are suitable for implementation
and that address the framework domains and
subdomains. Many of these practices are
based on published studies, or widely accepted
experiential or consensus information. Some of
the subdomains included in the framework do
not have endorsed preferred practices; how-
ever, this does not mean that the subdomain is

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not considered to be a critical component of
the framework. The preferred practices for this
project were evaluated for their adequacy
using NQF-endorsed standard evaluation
criteria for all practice evaluations (see Box A):

effectiveness – clear evidence must be
presented that indicates the practice would
be effective in improving outcomes;

generalizability – the practice should be
able to be utilized in multiple care settings
and/or for multiple types of patients;

benefit – it must be clear how the practice
would improve or increase the likelihood of
improving patient outcomes; and

readiness – the training, technology, and
staff required for implementation of the
practice are available.

Table 1 beginning on page 17, presents the
45 preferred practices and their specifications
cross-walked to the framework.

Box A: Criteria for Evaluation of Practices

Evidence of Effectiveness
There must be clear evidence that the practice (if appropriately implemented) would be effective
in improving outcomes (e.g., reduced substance use). Evidence may take various forms, including:
y research studies (syntheses) showing a direct connection between the practice and improved

clinical outcomes;
y experiential data (including broad expert agreement, widespread opinion, or professional

consensus) showing the practice is “obviously beneficial” or self-evident (i.e., the practice
absolutely forces an improvement to occur) or organization or program data linking the
practice to improved outcomes; or

y research findings or experiential data from other healthcare or non-healthcare settings that
should be substantially transferable.

Generalizability
The practice must be able to be utilized in multiple applicable clinical care settings
(e.g., a variety of inpatient and/or outpatient settings) and/or for multiple types of patients.

Benefit
If the practice (determined to be effective) were more widely utilized, it would improve or
increase the likelihood of improving patient outcomes (e.g., improved patient function). If an
effective practice already is in near universal use, its endorsement would lead to little new
benefit to patients.

Readiness
The necessary technology and appropriately skilled staff must be available to most healthcare
organizations. For this project, opportunity for measurement also was a consideration.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

National Quality Forum 17

more

Table 1: Preferred Practices and Specifications Cross-Walked to the Framework
DOMAIN SUBDOMAIN PRACTICE PRACTICE STATEMENT

NUMBER

Domain 1: Organizational 1 Create and sustain an environment
Leadership Culture (1.1) of cultural competency through

establishing leadership structures and
systems or embedding them into existing
structures and systems.

Organizational 2 Identify and develop informed and
Culture (1.1) committed champions of cultural

competency throughout the organization
in order to focus efforts around providing
culturally competent care.

Commitment to 3 Ensure that a commitment to culturally
Serving a Diverse competent care is reflected in the vision,
Population (1.2) goals, and mission of the organization,

and couple this with an actionable plan.

Leadership 4 Implement strategies to recruit, retain,
Diversity (1.3) and promote at all levels of the

organization a diverse leadership that
reflects the demographic characteristics
of the service area.

Dedicated Staff 5 Ensure that the necessary fiscal and
and Resources human resources, tools, skills, and
(1.4) knowledge to support and improve

culturally competent policies and practices
in the organization are available.

Policies (1.5) 6 Commit to cultural competency through
systemwide approaches that are
articulated through written policies,
practices, procedures, and programs.

Training and 7 Actively seek strategies to improve the
Development (1.6) knowledge and skills that are needed to

address cultural competency in the
organization.

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more
Table 1: Preferred Practices and Specifications Cross-Walked to the Framework
DOMAIN SUBDOMAIN PRACTICE PRACTICE STATEMENT
NUMBER

Domain 2: Strategic 8 Integrate into the organizational strategic
Integration into Planning (2.1) plan clear goals, policies, operational
Management procedures, and management
Systems and accountability/oversight mechanisms to
Operations provide culturally competent services.

Service 9 Implement language access planning in
Planning (2.2) any area where care is delivered.
Reward 10 Implement reward and recognition
Systems (2.4) programs to recognize specific individuals,

initiatives, and programs within the
organization that promote cultural
competency.

Marketing and 11 Market culturally competent services to
Public Relations the community to ensure that communities
(2.5) that need services receive the information.

Domain 3: Language 12 Offer and provide language access
Patient-Provider Access (3.1) resources in the patient’s primary written
Communication and spoken language at no cost, at all

points of contact, and in a timely manner
during all hours of operation, and provide
both verbal offers and written notices
informing patients of their right to receive
language assistance services free of
charge.

Language 13 Determine and document the linguistic
Access (3.1) needs of a patient or legal guardian at

first points of contact, and periodically
assess them throughout the healthcare
experience.

Interpreter 14 Maintain sufficient resources for
Services (3.2) communicating with patients in their

primary written and spoken languages
through qualified/competent interpreter
resources, such as competent bilingual or
multilingual staff, staff interpreters,
contracted interpreters from outside
agencies, remote interpreting services,
credentialed volunteers, and others, to
ensure timely and high-quality
communication.

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more
Table 1: Preferred Practices and Specifications Cross-Walked to the Framework
DOMAIN SUBDOMAIN PRACTICE PRACTICE STATEMENT
NUMBER

Domain 3: Translation 15 Translate all vital documents, at a
Patient-Provider Services (3.3) minimum, into the identified threshold
Communication languages for the community that is
(continued) eligible to be served.

Translation 16 Translate written materials that are not
Services (3.3) considered vital when it is determined

that a printed translation is needed for
effective communication.

Translation 17 Ensure that a qualified interpreter reads a
Services (3.3) document to a patient if the patient

cannot read the translated document.

Health Literacy 18 Use “teach back” as a patient engagement
Strategies (3.4) tool to enhance communication between

the healthcare provider and the patient
during clinical encounters.

Health Literacy 19 Communicate key information about the
Strategies (3.4) proposed treatments or procedures for

which patients are being asked to
provide informed consent.

Cultural 20 Regularly assess attitudes, practices,
Awareness (3.6) policies, and structures of all staff as a

necessary, effective, and systematic way
to plan for and incorporate cultural
competency within an organization.

Family 21 Include family members in healthcare
Centeredness (3.8) decisions, when requested by the patient,

when providing care for culturally diverse
populations.

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Table 1: Preferred Practices and Specifications Cross-Walked to the Framework
DOMAIN SUBDOMAIN PRACTICE PRACTICE STATEMENT
NUMBER

Domain 4: Clinical 22 If requested by the patient, provide
Care Delivery Encounter (4.1) resources such as provider directories
and Supporting that indicate the languages providers
Mechanisms speak, so that patients can have access

to this information.

Clinical 23 Develop and implement a comprehensive
Encounter (4.1) care plan that addresses cultural concerns.

Clinical 24 Consider cultural, spiritual, and religious
Encounter (4.1) beliefs that may complement or conflict

with standard medical care.

Physical 25 Adapt the physical environment where the
Environment (4.2) healthcare is being delivered to represent

the culture of the populations who access
their healthcare in that environment.

Coordination of 26 Use culturally appropriate care
Care (4.4) coordination services that take into

consideration the cultural diversity of the
populations seeking healthcare.

Health Information 27 Explore, evaluate, and consider the use
Technology (4.7) of multimedia approaches and health

information technology to enable the
provision of healthcare services that are
patient and family centered and culturally
tailored to the patient.

Domain 5: Recruitment and 28 Recruit and hire ethnically diverse
Workforce Diversity Retention (5.1) providers and staff at all levels, including
and Training management levels.

Recruitment and 29 Actively promote the retention of a
Retention (5.1) culturally diverse workforce through

organizational policies and programs.

Training 30 Implement training that builds a workforce
Commitment and that is able to address the cultural needs
Content (5.2) of patients and provide appropriate and

effective services as required by federal,
state, and local laws, regulations, and
organizational policies.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

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Table 1: Preferred Practices and Specifications Cross-Walked to the Framework
DOMAIN SUBDOMAIN PRACTICE PRACTICE STATEMENT
NUMBER

Domain 6: Community 31 Engage communities to ensure that
Community Outreach (6.1) healthcare providers (individual and
Engagement organizational) are aware of current and

changing patient populations and cultural
and communication needs and provide
opportunities to share resources and
information.

Community 32 Collaborate with the community to
Outreach (6.1) implement programs with clinical and

outreach components to address culturally
diverse populations, health disparities,
and equity in the community.

Community 33 Utilize a variety of formal and informal
Outreach (6.1) mechanisms to facilitate community and

patient involvement in designing,
implementing, and evaluating the
effectiveness of cultural competency
activities.

Community 34 Healthcare professionals and
Investments (6.3) organizations should engage communities

in building their assets as vehicles for
improving health outcomes.

Community-Based 35 Use the methodology of community-based
Participatory participatory research when conducting
Research (6.4) research in the community as a

collaborative approach to research that
equitably involves all stakeholders in the
research process and fosters the unique
strengths that the community brings to
the process.

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Table 1: Preferred Practices and Specifications Cross-Walked to the Framework
DOMAIN SUBDOMAIN PRACTICE PRACTICE STATEMENT
NUMBER

Domain 7: Collection of 36 Utilize the Health Research & Educational
Data Collection, Patient Cultural Trust (HRET) Disparities Toolkit to collect
Public Accountability, Competency-Related patient race/ethnicity and primary written
and Quality Information (7.1) and spoken language data from patients in
Improvement a systematic, uniform manner.

Collection of 37 Ensure that, at minimum, data on an
Patient Cultural individual patient’s race and ethnicity (using
Competency-Related the Office of Management and Budget
Information (7.1) categories as modified by HRET) and

primary written and spoken language are
collected in health records and integrated
into the organization’s management
information systems. Periodically update the
language information.

Collection of 38 Utilize indirect data collection
Community Cultural methodologies (e.g., geocoding, surname
Competency-Related analysis) to characterize the race, ethnicity,
Information (7.2) and primary written and spoken language

of a community for service planning and
conducting community-based targeted
interventions.

Collection of 39 Maintain a current demographic, cultural,
Community Cultural and epidemiological profile of the
Competency-Related community to accurately plan for and
Information (7.2) implement services that respond to the

cultural characteristics of the service area.

Quality 40 Apply a quality improvement framework to
Improvement (7.3) improve cultural competency and discover

and eliminate disparities in care using the
race, ethnicity, and primary written and
spoken language information collected by
the institution.

Accountability (7.4) 41 Publicly report data for the applicable
NQF-endorsed disparities-sensitive national
voluntary consensus standards for
ambulatory care stratified by race/ethnicity
and primary written and spoken language.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

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Table 1: Preferred Practices and Specifications Cross-Walked to the Framework
DOMAIN SUBDOMAIN PRACTICE PRACTICE STATEMENT
NUMBER

Domain 7: Accountability (7.4) 42 Regularly make available to the public
Data Collection, information about progress and successful
Public Accountability, innovations in implementing culturally
and Quality competent programs (especially the NQF-
Improvement endorsed preferred practices for cultural
(continued) competency), and provide public notice in

communities about the availability of this
information.

Assessment of 43 Assess and improve patient- and family-
Patient Experiences centered communication on an ongoing
with Care (7.5) basis.

Assessment of 44 Any surveys created by or conducted by the
Patient Experiences organization must collect race, ethnicity,
with Care (7.5) and primary written and spoken language,

and analysis and results must be stratified
by race, ethnicity, and primary written and
spoken language.

Documentation of 45 Ensure that conflict and grievance resolution
Cross-Cultural processes are culturally sensitive and
Complaints and capable of identifying, preventing, and
Resolutions (7.9) promptly and equitably resolving cross-

cultural conflicts or complaints by patients
or between organizational staff.

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Domain 1: Leadership
The Problem
The U.S. population continues to grow and
rapidly diversify among racial and ethnic
groups.136 It is projected that by the year
2050, Hispanics and foreign-born residents
will make up 48 percent of the U.S. popula-
tion.137 This large shift in demographics will
require changes within the healthcare system
to adjust the delivery of care for these increas-
ingly diverse populations. Culturally competent
care will become an increasingly important
component of the provision of healthcare
services. Culturally competent care directly
affects how care is delivered and received.138

Without it, care is not patient centered and is
likely to be inequitable.

It has become increasingly more difficult for
people to navigate and adapt to a healthcare
system that is not tailored to their needs.
Different patients speak different languages
and have different concepts about healthcare,
including beliefs and practices about disease
and treatments. Although this may present a
challenge to healthcare professionals who
have been trained in the concepts of Western
medicine, the burden of navigating the com-
plexities of healthcare should not fall solely on
the patient.139

Sociocultural differences among patients,
healthcare providers, and the healthcare
system can be viewed by healthcare experts
as potential causes for disparities. These
include variations in patients’ abilities to
recognize clinical symptoms of disease and
illness, different thresholds for seeking care,
differing expectations of care, and differences

in understanding prescribed treatments and
the decisions to follow those treatments.140

Differences between the patient and provider
also can influence providers’ decisionmaking
and interactions between patients and the
healthcare delivery system.141 Furthermore, a
patient’s satisfaction with care directly affects
his or her adherence to therapy and continuity
of care.142

Like general quality improvement or
improving patient safety, quality improvement
for cultural competency directly stems from
the leadership and culture of a healthcare
organization. Healthcare providers, clinical,
and organizational leaders, governance
boards, CEOs, and the community play an
essential role in developing and implementing
cultural competency initiatives, setting organi-
zational policy and strategy, and monitoring
organizational performance.

Leadership is multifaceted and should
include an organizational culture that is
committed to diversity and that has sufficient
staff and resources and appropriate policies
for implementation, governance, and training
and development.143 Studies have shown that
98 percent of senior leaders in healthcare
management do not reflect the population they
are serving.144 This important concern can be
addressed by ensuring that minority healthcare
professionals are included in sufficient numbers
in the healthcare workforce. In general, such
professionals would be more likely than non-
minority professionals to take into account a
range of sociocultural factors when organizing
healthcare delivery systems to meet the needs
of minority populations.145 Currently, community-
based organizations, healthcare organizations,
and healthcare professionals are beginning to

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

implement strategies to address racial/ethnic
disparities relevant to the populations they are
serving.146 Most of these adjustments include
those made to services and programs, but the
most important factor in providing culturally
appropriate care centers on the committed
involvement of leaders at all levels within an
organization.147

A commitment to culturally competent care
can be reflected through how an organization
plans its work and by its guiding principles
and policies.148 In addition, those who are
members of an organization should reflect
the populations they are serving.149 Research
continues to suggest that the cultural orientation
of the medical care system is not sufficiently
congruent with the cultural perceptions of the
patients.150 Leaders can improve this situation
by creating an organizational culture that
can serve as a model of culturally competent
behavior—for example, by designating an
individual responsible for managing cultural
competency programs, having formal plans
demonstrating how the needs of the diverse
population will be met, and providing funds
for initiatives.151 Ultimately, culturally competent
care must take a systemwide approach and
incorporate the active involvement of leader-
ship to ensure a continuing commitment to
providing patient-centered, equitable care.

Preferred Practices

Organizational Culture (1.1)
Preferred Practice 1: Create and sustain an
environment of cultural competency through
establishing leadership structures and systems
or embedding them into existing structures and
systems.

Specifications:
y Leadership support should be visible.

y Standardized policies and procedures
to facilitate cultural competency should:
1) ensure that organizational leadership is
knowledgeable about cultural competency
issues present within the organization and is
continuously involved in processes to assure
that the issues are appropriately addressed;
2) provide oversight and coordination of cul-
tural competency activities; and 3) provide
feedback to frontline healthcare providers
about lessons learned.

y Leadership should ensure that all staff are
trained in techniques of teamwork-based
problem solving and management.

y Leadership structures and systems should
ensure organization-wide awareness of
1) performance gaps (and they should
promote the direct accountability of leaders
for those gaps) and 2) performance assets
that can benefit through dissemination and
diffusion throughout the organization.

y Leadership should both communicate and
demonstrate through their personal behavior
that diversity and serving diversity well are
two of the values of the organization.

y Governance boards and senior administra-
tive leaders should be briefed regularly
regarding the organization’s cultural compe-
tency practices to understand how tightly
linked they are with providing quality care
and how the activities overlap.

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y Governance boards and senior administrative
leaders should become personally involved
in patient safety to comply with the practices
that will constitute the first step to transform-
ing the culture of the organization.

Preferred Practice 2: Identify and develop
informed and committed champions of cultural
competency throughout the organization
in order to focus efforts around providing
culturally competent care.

Specifications:
y Focus on midlevel manager champions

who recognize a need, hold enough power
to encourage change, and are capable
of building support.

y Establish champions at multiple levels of
the organization.

y Ensure that leadership support of the
champions is visible.

y Integrate interpreters and community
outreach workers on committees throughout
the organization.

y Integrate cultural competency as a component
of performance evaluations; demonstrate
technical skills, the ability to meet organi-
zational standards, and a commitment to
understanding patients’ cultures and
improving communication skills.

y Integrate cultural competency within the
larger measurement framework of the organ-
ization in order to reduce disparities and
increase the capacity of the organization to
provide culturally competent care.

y Ensure that leaders directly address the need
to improve communication about cultural
competency through initiatives, policies, and
presentations and that leaders are integrated
into ongoing projects.

Commitment to Serving a Diverse
Population (1.2)
Preferred Practice 3: Ensure that a commit-
ment to culturally competent care is reflected in
the vision, goals, and mission of the organiza-
tion, and couple this with an actionable plan.

Specifications:
y Make publicly available the vision, goals,

and mission of the organization and the
action plan for implementation, after
ensuring that staff members have had the
opportunity to provide input and comment.

y Update the action plan at least annually.

Leadership Diversity (1.3)
Preferred Practice 4: Implement strategies to
recruit, retain, and promote at all levels of the
organization a diverse leadership that reflects
the demographic characteristics of the service
area.

Specifications:
y Establish an internal mechanism for

developing strategies that involve using
a committee of current diverse staff for
recruitment, retention, and promotion.

y Conduct internal and external assessments
on how to address the need for staff
diversity.

y Engage with community leaders, and
specifically target and recruit from the
community served.

y Ensure that recruitment and selection
processes focus on meeting the needs
of the organization’s goals for culturally
competent care.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

Dedicated Staff and Resources (1.4)
Preferred Practice 5: Ensure that the
necessary fiscal and human resources, tools,
skills, and knowledge to support and improve
culturally competent policies and practices in
the organization are available.

Specifications:
y Leaders must consult with the care setting

managers, clinical leaders, language
service providers, and others to identify
needed fiscal and human resources to
appropriately meet the cultural needs of
patients. The demographic profile (see
Domain 7) may help inform this process.

y Leadership should provide staff, at all
levels, with the available time and resources
for training programs and practices that
promote culturally competent care.

y Ensure that continued training and coaching
on culturally competent care is available for
new and current staff.

y Document where the fiscal support for these
activities is within the organization.

y Ensure that there are budget line items and
specific allocations for cultural competency
activities and programs.

y Establish and enforce organizational
policies that support the allocation of fiscal
resources for cultural competency.

Policies (1.5)
Preferred Practice 6: Commit to cultural
competency through systemwide approaches
that are articulated through written policies,
practices, procedures, and programs.

Specifications:
y Establish a committee or another body (or

utilize an existing one) to ensure that cultural
competency is integrated systemwide; the
committee or body should be composed of
leaders and should report directly to the
governance board and other leaders.

y Leadership should develop and/or provide
the necessary professional development
training to staff, including all managers,
who will be accountable to the public in
matters regarding legal compliance and
accreditation requirements and for the orga-
nization’s policy on cultural competency.

y Leadership should ensure that cultural com-
petency policies are, with proper guidance,
consistently administered and implemented
across the departments.

y Leadership should involve diverse sectors
of the community in the planning, ongoing
feedback, and evaluation of programs and
services.

y An evaluation system should be implemented
to monitor and provide ongoing feedback
on the effectiveness of diversity and cultural
competency programs and strategies,
including employee training sessions.

y An advisory body of stakeholders should
be appointed and should meet quarterly
to facilitate community input and support
in implementing and evaluating cultural
competency standards.

y Information should be disseminated
continuously to all facilities and programs
on updated regulatory policies, regulations,
and accreditation guidelines related to
requirements involving cultural matters.

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Training and Development (1.6)
Preferred Practice 7: Actively seek strategies
to improve the knowledge and skills that are
needed to address cultural competency in the
organization.

Specifications:
y Training and development could include the

following content:

• in-depth knowledge of the causes and
research surrounding cultural competency,
inequities and healthcare disparities, and
the understanding of different cultural
beliefs and attitudes related to healthcare
and treatment for predominant populations
served by the organization;

• quality improvement strategies and skills
to address disparities;

• leadership skills to implement solutions
and help transform organizations;

• strategies to improve the cultural
competency of the organization;

• knowledge on the linkage between
cultural care; improved health outcomes,
legal requirements and policies, including
local, state, and federal standards;
quality of care issues; the importance of
the skilled use of qualified interpreters;
and information about the programs and
services offered; and

• knowledge of the cultural and linguistic
access policies of the organization,
including how to obtain language
assistance services.

y Management should develop and provide
training opportunities on diversity and
cultural competency for staff and senior
management, as well as for physicians,
nurses, allied professionals, and other
clinicians and providers.

Domain 2: Integration into
Management Systems and Operations
The Problem
Providing culturally competent care depends
largely on the willingness of organizations to
learn, adapt, and incorporate explicit strate-
gies into their guiding missions and goals.152

Appropriately addressing the healthcare
needs of diverse populations involves an
organization’s total commitment; culturally
appropriate services must be integrated to
ensure that supportive infrastructure is in place
for implementation.153 Without an organiza-
tional commitment to cultural competency and
a plan of action, initiatives often can be over-
looked by other organizational priorities.154

Integrating culturally competent care into man-
agement systems involves strategic planning,
service planning, and marketing, in addition
to using continuous improvement systems for
staff that include performance evaluations and
reward systems.

Strategic planning helps an organization
define its structural activities, develop policies,
and set goals relevant to culturally appropriate
services.155 A key component for planning is
leadership support, which serves to recognize,
prioritize, and drive many of the needed
efforts.156 Most healthcare systems and structural
processes are shaped and defined by leader-
ship; with adequate management systems,
services continue to flourish, and commitment
from all staff members is achievable.157

Strategic planning ultimately helps a healthcare
organization identify, monitor, and evaluate
system features that may require the implemen-
tation of new policies or programs to stay

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

consistent with the organization’s overall
mission.158

The planning of services is closely integrated
with strategic planning. Designing services that
meet the needs of a diverse patient population
is vitally important and should cover all elements
involved in healthcare encounters. Examples
include ensuring that accurate communication
occurs between the patient and provider, that
the provider adapts services to accommodate
religious or dietary preferences, and that clinic
hours are expanded to accommodate a range
of schedules.159 Specific services should be
planned for diverse communities, and appro-
priate marketing strategies should be imple-
mented. Marketing services to the community
should encompass a broad array of outlets,
such as ethnic newspapers, common gathering
areas, such as churches, and television/radio
advertising. A targeted approach helps to
ensure that information is available to those
who need healthcare services and creates
opportunities for providers, patients, and the
general community to work together to
improve the care provided.

A separate but equally important aspect to
the integration of culturally competent services
is sustainable support from staff. This can be
achieved through many avenues, including the
use of performance evaluations and reward
systems. Evaluation systems are essential for
achieving accountability, identifying problems,
and developing an approach for making
improvements. Audits are also used at some
organizations to determine whether the core
structure of the workforce is knowledgeable
and represents the needs of diverse communi-
ties.160 One management tool that is widely
recognized is incentivizing behavior. Rigorous

award programs such as the Malcolm Baldrige
National Quality Award or the NCQA
Recognizing Innovation in Multicultural Health
Care award program require the submission of
evidence of impact as part of the application.
These programs require the applicant to
measure and evaluate its program and that the
program demonstrates improvement. Striving to
be recognized by an award program arguably
could be considered to drive improvement.

Organizational policies and procedures
can provide a supportive base for meeting the
needs of diverse populations. A supportive
infrastructure is the first and most important
step needed to integrate cultural competency
into management systems and operations.161

Preferred Practices

Strategic Planning (2.1)
Preferred Practice 8: Integrate into the
organizational strategic plan clear goals,
policies, operational procedures, and manage-
ment accountability/oversight mechanisms to
provide culturally competent services. (This
preferred practice also relates to the Leadership
subdomains of Policies and Commitment to
Serving a Diverse Population and the Data
Collection, Public Accountability, and Quality
Improvement subdomains of Accountability
and Performance Management Systems.)

Specifications:
y A strategic plan should be developed with

the participation of consumers, community,
and staff who can convey the needs and
concerns of all communities and all parts of
the organization affected.

y Any results from data gathering and self-
assessment processes should inform the
development and refinement of goals, plans,
and policies.

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Service Planning (2.2)
Preferred Practice 9: Implement language
access planning in any area where care is
delivered.

Specifications:
y A language services coordinator should

be a staff member who is designated to
coordinate all language service activities,
and this coordinator should be familiar with
the service needs of the LEP population, the
resources available in the community, and
potential partners and funding sources for
meeting the identified needs.

y Written language plans should be developed
that identify language needs and set forth
the organization’s strategy for meeting those
needs. Having such a plan also is evidence
of a provider’s compliance with Title VI.viii,162

y A language service delivery plan should be
developed. The manual should include, but
not be limited to, copies of staff interpreter
job descriptions, language service protocols,
training modules for bilingual staff, transla-
tions of vital documents, and signage.

Reward Systems (2.4)
Preferred Practice 10: Implement reward and
recognition programs to recognize specific
individuals, initiatives, and programs within the
organization that promote cultural competency.

Specifications:
y Establish standardized evaluation criteria to

assess individuals, initiatives, and programs
on equal par with other recognition activities
and awards.

y Reward individuals, initiatives, or programs
that improve cultural competency and
reduce health disparities or that go beyond
the preferred practices in this document.

Marketing and Public Relations (2.5)
Preferred Practice 11: Market culturally
competent services to the community to ensure
that communities that need services receive the
information.

Specifications:
y Identify a staff member who is responsible

for facilitating communication with communi-
ties about culturally competent services.

y Use social marketing campaigns to ensure
that the community is aware of the health-
care disparities in the area and how the
organization or provider addresses those
disparities.

Domain 3:
Patient-Provider Communication
The Problem
There is a mounting barrier to healthcare
quality—problems involving communication
between providers and patients. Even when
the provider and the patient speak the same
language, their communication is generally not
optimal, and the patient’s understanding of the
interaction is lacking.163 Today, approximately
49.6 million Americans speak a language
other than English at home, and 23.3 million
have LEP.164 With the growing diversity of the
U.S. population, a dialogue on healthcare
becomes more difficult. Clear patient-provider
communication is essential for effective care
and directly affects the quality of care that
is provided, including recovery time and
adherence.165

viii Title VI mandates that health and human service providers ensure that those with LEP can meaningfully access
programs and services and a variety of additional sources, including federal and state laws and regulations, managed
care contracts, and healthcare accreditation organizations.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

Communication is both verbal and nonver-
bal and includes language access, interpreter
services, written communication, and body lan-
guage. It also involves personal characteristics,
social attitudes and values, race, ethnicity,
sexual orientation, age, gender, education,
and physical and mental health.166 More
effective patient-provider communication can
lead to better self-care behavior as well as
improvements in health outcomes.167

When it comes to receiving healthcare,
language barriers often are considered to
be as significant as the barriers presented by
the lack of health insurance.168 Language
barriers manifest not only through spoken
language, but also through interpreters,
translation services, health literacy strategies,
cultural awareness, and cross-cultural com-
munication skills. Additionally, health status is
influenced not only by individual attributes
such as genetics and health behaviors, but
also by the patient’s culture.169 Patients who
face language barriers are less likely to have
a usual source of preventive care, and they
have an increased risk of nonadherence to
medication.170 Often, those who have difficulty
speaking English use physician services less,
and they are less likely to keep follow-up
appointments.171 Inadequate communication
also leads to delayed care and ultimately
can cost a hospital more money because of
malpractice settlements.172

Legally, patients seeking services must be
offered a qualified interpreter regardless of
the language spoken or the cost involved,
and organizations should maintain sufficient
services and resources to do so. Currently,
however, interpreter services are provided ad
hoc in some instances, using other patients,

family members, and nonclinical personnel.
These ad hoc services usually have negative
consequences, such as reduced physician trust,
lower patient satisfaction, inaccurate communi-
cation, breach of patient confidentiality, and
inadequate diagnosis.173 According to one
study, interpreters were not used in 46 percent
of emergency department cases involving LEP
patients.174 Also, even if services are available,
many people in a service area, especially
individuals with LEP, may be unaware of an
organization’s services and never utilize its
programs.

Written communication serves a role that is
just as important as that of verbal communica-
tion. Materials provided to patients should be
translated into the common language(s) for the
provider’s service population. Relevant infor-
mation includes applications, consent forms,
preventive and treatment instructions, and
patient education materials.175

Translations must be evaluated for content,
as well as reading level. In one study of
informed consent for surgery and other
procedures, the mean educational grade level
required to understand consent forms was
12.6—which is equivalent to some college
education.176 Even the small proportion of
consent forms that are written at a lower grade
level may well be inaccessible to many people.
Based on the 2003 National Adult Literacy
Survey, only 12 percent of adults had a profi-
cient health literacy level. Patients’ “functional
health literacy,”177 resulting from a lack of
familiarity with healthcare terms and phrases,
may be much worse than their general literacy;
IOM estimates that 90 million (47 percent) of
U.S. adults have limited health literacy.178

Adding LEP on top of health literacy barriers

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means that patients with limited literacy and
LEP who undergo surgical procedures have
little understanding about risks or alternative
options and even less opportunity to intervene
if an obvious error is about to occur.

Effective patient-provider communication
also may involve integrating the family and
its values in standard care. Family-centered
care when healthcare decisions are made is
especially important for certain cultures.179

One study revealed that Korean and Mexican
Americans prefer a family-centered model of
care, particularly with respect to decisions
about terminal conditions and treatments.180

And, in some cases, family members may
serve as the decisionmaker, even replacing
the patient. A lack of accommodation in this
regard may result in a noncompliant patient
and a decrease in quality of care.181

Providers should be equipped with the
knowledge, skills, and resources they need to
address barriers within a culturally diverse
population. There are clear benefits that accrue
from cultural awareness and professional
training. A pilot study of second-year medical
students captured a baseline measure of cultural
elicitation use by the students. A six-hour inter-
vention followed that included an assessment
of cultural beliefs and attitudes, reading and
discussion, culture and its role in illness, and
self-assessment exercises. Results revealed
that, from baseline, all subjects increased their
use of cultural elicitation after the intervention,
and all subjects spent more time with their
patients.182

High-quality services are needed at all
points of contact with patients with LEP, not
just communication between patients and

healthcare professionals.183 Thoughtful and
appropriate language access and adequate
strategic planning will help in assessing patient
language needs and will allow potential
activities and costs to be analyzed and
programs to be developed.184

Preferred Practices

Language Access (3.1)
Preferred Practice 12: Offer and provide
language access resources in the patient’s
primary written and spoken language at no
cost, at all points of contact, and in a timely
manner during all hours of operation, and
provide both verbal offers and written notices
informing patients of their right to receive
language assistance services free of charge.

Specifications:
y Language resources encompass competent

interpreters (staff, contractors from outside
agencies, remote telephonic or video inter-
preting services, or credentialed volunteers)
and/or bilingual/multilingual clinical staff
for clinical encounters, as well as bilingual/
multilingual general staff as navigators for
other encounters (e.g., to assist in making
appointments, assist with transfers within a
facility).

y All staff providing interpreting services or
care directly provided in another language
to patients should be qualified, assessed,
and monitored to determine competency to
provide services in healthcare settings.

y Timely access to interpreter services is
particularly critical in certain service areas
such as emergency departments.

y Title VI, at a minimum, should guide
language access resource policies.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

y LEP individuals should be informed—in their
primary language—that they have the right
to free language services and that such
services are readily available.

y At all points of contact, healthcare organiza-
tions should distribute written notices with
this information and post translated signage
that language services are available free of
charge.

y Patients should be explicitly asked about
their primary written and spoken language,
and the information should be noted in all
records; the primary language of each
patient is the language he or she feels most
comfortable using in a clinical or nonclinical
encounter.

y Informing patients about language assis-
tance services should include one or more
of the following efforts: 1) use language
identification or “I speak…” cards; 2) post
and maintain signs in regularly encountered
languages at all points of entry; 3) create
and use uniform procedures for timely and
effective telephone communication between
staff and LEP patients; and 4) include state-
ments about the services available and the
right to free language assistance services
in appropriate non-English languages in
brochures, booklets, outreach materials, and
other materials that are routinely distributed
to the public.

Preferred Practice 13: Determine and
document the linguistic needs of a patient
or legal guardian at first points of contact,
and periodically assess them throughout the
healthcare experience.

Specifications:
y Use the following questions from the Health

Research & Educational Trust (HRET) toolkit:
1) What language do you feel most comfort-
able speaking with your doctor or nurse?
2) How would you rate your ability to speak

and understand English? 3) Would you like
an interpreter? 4) In which language would
you feel most comfortable reading medical
or healthcare instructions? and 5) How
satisfied are you with your ability to read
English?

y Providers should take steps to introduce
language access at the first points of patient
contact through, for example, posters and
cards used by front desk staff to identify and
document patients’ language needs.

y Document the ways in which the linguistic
needs of a patient or legal representative
have been met by the healthcare facility or
provider.

y Telephone reception issues should be
addressed to help to ensure that LEP patients
can effectively communicate with office staff.
Generally, a bilingual staff member should
answer the telephone; if not, an English-
speaking staff member should immediately
request assistance from a bilingual staff
person or should use remote translation
services.

y Ensure that answering services or telephone
answering machines provide information
to LEP individuals, particularly after-hours
callers. This may include statements in
multiple languages that inform callers how
to contact emergency services.

y Create an easily accessible record of the
primary language written and spoken by
patients by developing a coding system
that can be used for computer and chart
notations.

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Interpreter Services (3.2)
Preferred Practice 14: Maintain sufficient
resources for communicating with patients in
their primary written and spoken languages
through qualified/competent interpreter
resources, such as competent bilingual or
multilingual staff, staff interpreters, contracted
interpreters from outside agencies, remote
interpreting services, credentialed volunteers,
and others, to ensure timely and high-quality
communication.

Specifications:
y Sufficient resources encompass competent

interpreters (staff, contractors from outside
agencies, remote telephonic or video inter-
preting services, or credentialed volunteers)
and/or bilingual/multilingual clinical staff
for clinical encounters, as well as bilingual/
multilingual general staff as navigators for
other encounters (e.g., to assist in making
appointments, assist with transfers within a
facility).

y All individuals providing interpreting services
or providing direct care in another language
should be qualified, assessed, and monitored
to determine their language competency in
healthcare settings.

y All bilingual/multilingual staff and providers
should be assessed and monitored to
determine their competency.

y Minors, children, family members, and
friends may not be used to provide interpret-
ing services, except in life-threatening
emergencies.

y Clinicians should receive training on how to
work effectively with language services.

y Organizations should ensure that their
interpreting services adhere to the National
Council on Interpreting in Health Care’s
National Standards of Practice for
Interpreters in Health Care and National
Code of Ethics for Interpreters in Health
Care.

y The facility should post and maintain a sign,
similar in size and legibility to the Hill-Burton
Community Service notices supplied by
DHHS under the provisions of 42 C.F.R.
124.604(a), informing the public of the
availability of interpreter services at all
points of contact.

Translation Services (3.3)
Preferred Practice 15: Translate all vital
documents, at a minimum, into the identified
threshold ix languages for the community that is
eligible to be served.

Specifications:
y An organization should develop a standard

policy, including available resources, to
ensure competent communication of vital
documents that are for nonthreshold
languages.

y If a vital document is not translated, a
qualified interpreter should be used to
translate the documents free of charge, and
notice of the availability of an interpreter
should be provided to LEP patients.

y Vital documents requiring translation include
but are not limited to:

• therapeutic trial consent forms;

• signage and way-finding directions;

• patient intake forms;

ix Title 9 of the California Code of Regulations, Section 1810.410, addresses the Cultural and Linguistic Requirements of
the public mental health systems in California. Section 1810.410(f) defines threshold language as a primary language
spoken by 3,000 people or 5 percent of the beneficiary population, whichever is lower in an identified geographic
area. However, state requirements may vary, so be sure to follow your state’s requirement.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

• consent forms for, but not limited to,
medical treatment, surgery, anesthesia,
inpatient psychiatric treatment, diagnostic
tests, and advance directives;

• patient complaint forms and grievance
process forms;

• letters and notices pertaining to the
reduction, denial, or termination of
services or benefits;

• letters or notices that require a response
from the beneficiary or client;

• documents that advise of the availability
of free language assistance;

• documents that provide information on
emergency health issues;

• documents that provide information about
patient rights and responsibilities;

• documents that provide billing and
financial information;

• documents that provide general
information on current clinical trials
being conducted within the facility and
opportunities to participate in them;

• applications for federal/state health
and social services programs, including
information about the availability of
financial assistance;

• consent forms for releasing medical
information;

• appointment reminder notices;

• key health education materials;

• HIPAA Privacy Notices;

• discharge instructions; and

• medication instructions.

Preferred Practice 16: Translate written mate-
rials that are not considered vital when it is
determined that a printed translation is needed
for effective communication.

Specifications:
y Organizations should develop a standard

policy to ensure competent communication
and translation of documents that are not
considered vital.

y At a minimum, materials such as comment
and feedback cards, patient satisfaction
surveys, and other materials soliciting feed-
back from patients and their families should
be included in the policy.

Preferred Practice 17: Ensure that a qualified
interpreter reads a document to a patient if the
patient cannot read the translated document.

Specifications:
y An Interpreter Attestation Form shall be

completed when an interpreter is interpret-
ing a discussion between a patient and a
physician relating to a medical procedure,
particularly when that discussion is for the
purpose of obtaining an informed consent
for treatment, and/or for those instances
when sight/oral translation of the written
information contained on the informed con-
sent form in the presence of the healthcare
provider has been used. If the interpretation
was done remotely, then the form should be
filled out and sent electronically or faxed to
the healthcare provider.

y The form shall be signed by the interpreter to
verify that the information was interpreted,
and it should be attached along with the
consent to the medical record.

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Health Literacy Strategies (3.4)
Preferred Practice 18: Use “teach back”
as a patient engagement tool to enhance com-
munication between the healthcare provider
and the patient during clinical encounters.

Specifications:
y At a minimum, patients should be able

to explain, in their everyday words, the
diagnosis/health problem for which they
need care and instructions for the prevention
and/or treatment of conditions.

y “Teach back” should begin early in the
process of patient care decisionmaking to
ensure that patients have time to understand
and think about their care options.

y Questions that begin with phrases such as
“I want to be sure we have the same under-
standing…,” “Please tell me in your own
words…,” and “This is important for your
safety…,” asked by healthcare professionals
through interpreters will allow patients to
relay or teach back that they understand
what they have been told.

y Consider using a standardized approach to
educating providers that promotes adequate
communication and informed consent and
one that appreciates the implications of
limited health literacy.

y Use new staff orientations and ongoing
educational and peer reinforcement events
to teach the process of improving communi-
cation, which should include specifically
telling patients that to help ensure better
communication they need to state in their
own words what the provider discussed
with them.

y Children also should be assessed for their
understanding of their condition, taking into
account developmental stage.

Preferred Practice 19: Communicate key
information about the proposed treatments or
procedures for which patients are being asked
to provide informed consent.

Specifications:
y Ask each patient or legal surrogate to

teach back in his or her own words key
information about the proposed treatments
or procedures for which he or she is being
asked to provide informed consent.185

y At a minimum, patients should be able to
explain, in their everyday words, the diag-
nosis/health problem for which they need
care; the name/type/general nature of the
treatment, service, or procedure, including
what receiving it will entail; and the primary
risks, benefits, and alternatives.

y Informed consent documents for use with a
patient should be written at or below the
5th-grade level and in the primary language
of the patient.

y Engage the patient, and, as appropriate,
the family and other decisionmakers, in a
dialogue about the nature and scope of the
procedure for which consent is being
sought.

y Provide a qualified medical interpreter or
reader to assist patients with LEP and limited
health literacy patients and patients with
visual or hearing impairments.

y This practice encompasses both informed
consent as well as assent by adolescent
patients.

y Children also should be assessed for their
understanding of their condition, taking into
account developmental stage.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

Cultural Awareness (3.6)
Preferred Practice 20: Regularly assess
attitudes, practices, policies, and structures
of all staff as a necessary, effective, and
systematic way to plan for and incorporate
cultural competency within an organization.

Specifications:
y The assessment must be conducted in an

environment that 1) offers participants a
forum to provide honest statements regard-
ing their level of awareness, knowledge,
and skills related to cultural competency;
2) provides participants an opportunity to
share their individual perspectives in a
candid manner; and 3) assures that the
information provided will be used to effect
meaningful change within the organization.186

y The assessment must solicit and value the
experiences and perspectives of patients
and families who receive services.

y Results should be used to strategically plan
long- and short-term objectives to enhance
the organization’s capacity to deliver cultur-
ally competent services by all levels within
the organization, including policymakers,
administrators, providers, subcontractors,
and consumers, and at both the state and
local levels.

y Assessment results must be shared with
participants and key stakeholders in a
manner that meets their unique needs.

y A quality improvement framework should be
used to make improvements.

Family Centeredness (3.8)
Preferred Practice 21: Include family mem-
bers in healthcare decisions, when requested
by the patient, when providing care for
culturally diverse populations.

Specifications:
y Healthcare providers listen to and honor

patient and family perspectives and choices.

y Patient and family knowledge, values,
beliefs, and cultural backgrounds are
incorporated into care planning and
decisionmaking.

y Healthcare providers communicate and
share complete and unbiased information
with patients and families in ways that are
affirming, respectful, and useful.

y Patients and families receive timely,
complete, and accurate information in
order to effectively participate in care and
decisionmaking.

y Patients and families are encouraged
and supported in participating in care and
decisionmaking at the level they choose.

y Patients, families, and providers collaborate
in policy and program development, imple-
mentation, and assessment; in healthcare
facility design; and in professional educa-
tion—as well as in the delivery of care.

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Domain 4: Care Delivery and
Supporting Mechanisms
The Problem
Many potential causes contribute to healthcare
disparities and to the fact that culturally diverse
patients have different levels of satisfaction
with the care they receive. Recent studies,
however, have indicated that variations in
patients’ health beliefs, values, preferences,
and behaviors play an important role.187,188,189

The burden of adapting to and navigating
through a healthcare environment should not
be place solely on the patient. Healthcare
professionals and organizations should think
proactively and incorporate initiatives and
activities that address the needs of diverse
populations.190

Lack of culturally competent care is not
an abstract concept that affects only patient
perception of care. For example, data from
communities involved in the Robert Wood
Johnson Foundation’s initiative Expecting
Success: Excellence in Cardiac Care indicate
that a number of characteristics of healthcare
providers may affect culturally diverse popula-
tions’ access to heart healthcare and contribute
to disparities. The factors are market competi-
tion; the growing trend of market segmentation;
the lack of dedicated resources to provide care
for the uninsured; referral arrangements; and
the frequent need to coordinate cardiac care
across multiple sites and providers.191

Important variations also exist in the way
that diverse populations communicate with
their providers, and these variations may affect

the kind of care they receive. This can include
variations in patient descriptions, recognition,
and communication of symptoms, variations
regarding when patients seek care, and varia-
tions in the comprehension of the prescribed
management strategy and adherence.192 In
addition, spirituality is an important factor
in healthcare delivery, particularly among
culturally diverse populations, yet it is often
neglected.193 Although up to 77 percent of
patients would like spiritual/religious issues to
be considered as part of their medical care,
only 10 to 20 percent of caregivers discuss
these issues with their patients.194 Spirituality
and religion often are considered a significant
component of culture, and as the healthcare
system incorporates changes to reflect culturally
competent care, the effects of religion and
spirituality on patient safety and care also
should be considered.

Providing culturally competent care means
properly addressing the manner in which
care is delivered, the physical environment
where that care is delivered, and linkages
with supportive services and providers.
Without a comprehensive, holistic approach,
it will be difficult to eliminate the inequities
in healthcare services that are provided to
minority populations.

When addressing care delivery and its
supporting mechanisms, it is important to
promote collaboration with other industry
stakeholders to share best practices, promote
the use of educational materials, and coordi-
nate outreach efforts.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency
Preferred Practices

Clinical Encounter (4.1)
Preferred Practice 22: If requested by the
patient, provide resources such as provider
directories that indicate the languages
providers speak, so that patients can have
access to this information.

Specifications:
y In order to be included in such a directory,

providers should be assessed for language
proficiency if it is not their native language.

y The directory should be easy to read and
provided in an accessible format.

y The directory should be created by individu-
als who understand the various languages
and cultures that are included.

Preferred Practice 23: Develop and
implement a comprehensive care plan that
addresses cultural concerns.

Specifications:
y The care plan should be developed with

patients and their caregivers.

y The care plan should note patients’ and fam-
ilies’ primary written and spoken languages
and any cultural beliefs that might affect the
care plan, including but not limited to those
involving spirituality/religion, nation of
origin, and ethnicity.

Preferred Practice 24: Consider cultural,
spiritual, and religious beliefs that may comple-
ment or conflict with standard medical care.

Specifications:
y Organization should have specific written

policies and procedures in place that
address exceptions to standard medical
care for religious and spiritual reasons (e.g.,
legal cases involving services such as blood
transfusions).

y Policies should be accepting of the benefits
of spiritual/religious beliefs.

Physical Environment (4.2)
Preferred Practice 25: Adapt the physical
environment where the healthcare is being
delivered to represent the culture of the
populations who access their healthcare in
that environment.

Specifications:
y Prominently display images, artwork, and

other decor that reflects, and does not
offend, the cultures and ethnic backgrounds
of the clients served.

y Provide magazines, brochures, and other
printed materials in reception areas that are
of interest to and reflect the different cultures
of the individuals and families served.

y When using videos, films, or other media
resources for health education, treatment, or
other interventions, ensure that they reflect
the cultures and ethnic background of the
individuals and families served.

y Ensure that printed information disseminated
takes into account the average literacy levels
of the individuals and families receiving
services.

Coordination of Care (4.4)
Preferred Practice 26: Use culturally appro-
priate care coordination services that take
into consideration the cultural diversity of the
populations seeking healthcare.

Specifications:
y Identify a staff person to coordinate services

that reflects the community being served.

y Put systems in place to track referrals and
services.

y Follow up on referrals and services to track
their completion.

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y Intervene with patients who are not getting
the services that were referred.

Health Information Technology (4.7)
Preferred Practice 27: Explore, evaluate, and
consider the use of multimedia approaches
and health information technology to enable
the provision of healthcare services that are
patient and family centered and culturally
tailored to the patient.

Specifications:
y Electronic health records should be

equipped to capture the race, ethnicity,
and primary written and spoken languages
of patients.

y When an electronic health record is used,
appropriate information should be shared
with patients, taking into account language,
cultural diversity, and values.

y Utilize multimedia or health information
technology that incorporates the needs
of diverse populations to accommodate
language, cultural diversity, and health
literacy.

y Technology should be adaptable and
available to diverse populations with
different primary languages and health
literacy levels.

Domain 5:
Workforce Diversity and Training
The Problem
There is growing evidence that racial and
ethnic concordance between providers and
patients improves patients’ satisfaction,
adherence to treatment, and health outcomes.195

Other evidence suggests that when providers
engage a patient in his or her own language,
rapport, quality of communication, and
understanding increases.196 Put simply, it is
important to have the appropriate staff and
resources available to serve diverse popula-
tions. Failure in these areas leads to a lack of
quality patient care, poor adherence, poor
coordination of treatments, and misunderstand-
ings. For example, research suggests that
patients who are racially or ethnically diverse
are more likely to perceive a bias on the part
of their providers and often do not follow up
when seeking treatment.197 A lack of cultural
competency and sensitivity among providers
may contribute to this problem.198

Having a diverse healthcare workforce is
not a panacea, but it clearly can improve
access to high-quality care for underserved
individuals and increase patient satisfaction
with care, expand the pool of medical profes-
sionals who may serve as policymakers or
managers, strengthen the medical research
agenda, and, most importantly, advance
culturally competent care. Several studies have
pointed to the links between the racial and
ethnic diversity of the healthcare workforce
and healthcare quality.199 For example, studies
have found that when there is racial concor-
dance between doctor and patient—that is,

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

when they share the same racial or ethnic
background—patient satisfaction and self-rated
quality of care are higher than when racial
or ethnic concordance is not present.200

Additionally, patient-centered and effective
treatment of people of all backgrounds
requires that healthcare providers be knowl-
edgeable about cultural belief systems, ethnic
origins, nontraditional treatments, and the
influence of family structures.201 Addressing
such constructs of culture does not necessarily
come from textbooks; it lends itself more
to involvement in the environments of the
populations being served.

Developing a diverse workforce that reflects
the community and the patient population
involves the recruitment and retention of a
diverse administrative and clinical staff.202

With the proper strategies in place to recruit,
retain, and train staff for the provision of cultur-
ally appropriate care, patient trust will increase
and the overall quality of care will improve.

A commitment to provide training to health-
care personnel to address the needs of a
culturally diverse population is important to
attaining cultural competency, given the current
demographics of the healthcare workforce.
Difficulties in the healthcare system may range
from language barriers around informed con-
sent, to problems accessing services or being
denied services, to outright discriminatory or
culturally insensitive treatment.203 Training that
includes the skills and knowledge that support
culturally competent care should be readily
available for staff—and in particular for staff
who have both clinical or nonclinical patient
contact. This training also should be available

for senior managers and administrators.204 The
training should go beyond addressing issues
related to patients having access to providers
who can speak with patients in their primary
written and spoken languages; it must also
include changes to the workplace environment
and in the availability of resources.205

Ultimately, policies, practices, procedures,
and programs addressing workforce diversity
and training should be integrated systemwide
to provide a more meaningful and effective
commitment to the delivery of culturally
competent care.

Preferred Practices

Recruitment and Retention (5.1)
Preferred Practice 28: Recruit and hire
ethnically diverse providers and staff at all
levels, including management levels.

Specifications:
y In order to support an organizational culture

that can better serve the community, promote
a system to recruit and retain qualified staff
from diverse backgrounds who understand
their patients’ cultures and communities.

y Human resource managers should assess
and report on employee promotions,
terminations, and resignations, and should
use exit interviews to evaluate how well
the organization is doing in promoting
and retaining a diverse workforce.

y Annually assess the organization’s progress
in recruiting, hiring, and retaining qualified
bicultural/multicultural employees.

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Practice Statement 29: Actively promote the
retention of a culturally diverse workforce
through organizational policies and programs.

Specifications:
y Regarding the recruitment and selection

process, focus on meeting the needs of the
organization’s goals for culturally competent
care.

y Adopt a personnel policy that creates a
comfortable and welcoming work place for
employees.

y Have senior executives mentor culturally
diverse employees.

y Subcontract with culturally diverse health-
care providers.

y Link executive compensation to the steps
that are taken to match hiring to community
needs.

y Expand on traditional affirmative action
programs aimed at attracting employees
who match the race and ethnicity of the
patient populations.

y Establish a set of principles for the respectful
treatment of all people.

y Review the fairness of human resource
practices and the compensation of all staff.

y Track staff satisfaction by racial and ethnic
groups.

Training Commitment and Content (5.2)
Preferred Practice 30: Implement training that
builds a workforce that is able to address the
cultural needs of patients and provide appro-
priate and effective services as required by
federal, state, and local laws, regulations, and
organizational policies. (See also the Leadership
subdomain of Policies.)

Specifications:
y Include in training materials information

regarding in-depth knowledge about the
causes of and research on cultural compe-
tency, inequities, and healthcare disparities.
Also include material related to healthcare
and treatment regarding understanding the
different cultural beliefs and attitudes of the
predominant populations served by the
organization.

y Promote a system to recruit and retain
qualified staff from diverse backgrounds
who understand their patient cultures
and communities, in order to support
organizational cultures that can better
serve communities.

y Provide training opportunities to increase
cultural competency skills to assist staff with
their responsibilities for direct patient care.

y Annually assess the organization’s progress
in recruiting, hiring, and retaining qualified
bicultural/multicultural employees.

y Human resource managers should assess
and report on employee promotions,
terminations, and resignations, and
should include the use of exit interviews,
to evaluate how well the organization is
doing in the promotion and retention of a
diverse workforce.

Domain Six: Community Engagement
The Problem
An important element in improving the
provision of culturally competent care and
reducing health disparities is one that centers
on community engagement. Integrating an
understanding of community needs with com-
munity collaborations among health institutions,
providers, and outreach workers can improve
care quality for diverse populations.206

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

Healthcare professionals and organizations
should understand the communities they serve,
including the social structures and environmen-
tal factors that affect health and the perceptions
of healthcare.207 Such community engagement
is multifaceted and involves many components,
such as conducting needs assessments and
community outreach, involving community
leaders in program development and decision-
making processes, and engaging in CBPR.

Healthcare organizations need to understand
their communities, as well as their patient/
consumer populations, to provide quality
healthcare services. For example, developers
of programs often are not sensitive to the
cultural norms and boundaries that support or
hinder behaviors related to screening, early
detection, and prevention.208 Without informed
knowledge about communities and culture,
important health and healthcare programs
usually are not successful or sustainable.209

Of note, data collection about potential, as
well as current, patient populations is important,
as is the utilization of as many data sources
as possible, including sources outside of the
organization itself. Because the characteristics
of a community change over time, it also is
critical that healthcare organizations ensure
that the data they have about their community
are up to date. Demographic, cultural, and
epidemiological profiles of the community and
needs assessments are tools to help organiza-
tions understand their communities, and they
can help providers and policymakers develop
appropriate services and evaluate access to,
and utilization of, those services.

A critical component of community engage-
ment involves forming partnerships with leaders,
including but not limited to spiritual and social

leaders, community members, and other
community networks. Such partnerships clearly
can have a positive impact on the health of
minority populations. For example, a community
partnership with the Haitian community in the
Tampa Bay area resulted in more than 80
Haitian women receiving mammograms and
clinical breast examinations and approximately
4,500 people receiving educational messages
about breast cancer.210 Support from community
gatekeepers, such as clergy, local Haitian
nonprofit organizations, and a Haitian outreach
worker, helped broaden community interest
and provided legitimacy and sustainability to
the program.211

CBPR also provides an opportunity to tackle
health disparities in communities.212 An assess-
ment of CBPR in environmental and occupa-
tional health in the United States found clear
evidence that CBPR results in actions that effect
community-level change.213 In 14 of 20 studies,
CBPR led to community-level action to improve
the health and well-being of the community
members. Observational studies that investigated
problems posed by the affected community
and that incorporated qualitative methods
were more likely to lead to action. The collabo-
ration among government scientists, university
researchers, and community partners emerged
as a new model of CBPR partnerships that
effectively integrate research and action.
Community needs assessments, partnerships,
and CBPR are all considered to be investments.

Robust community engagement has clear
benefits for patients, the healthcare community,
and the greater healthcare system. A study
conducted by the Trust for America’s Health
found that investing $10 per person per year
in community disease prevention programs

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could save the United States $2.8 billion in
healthcare costs over two years and $16.5
billion over five years.214 The study analyzed
community-based prevention programs that
promote physical activity, good nutrition, and
smoking cessation. Among the findings were
that community health programs could reduce
the rates of diabetes and high blood pressure
by 5 percent within 2 years and reduce the
incidence of some forms of cancer and arthritis
within 10 to 20 years.215

Community engagement is a cornerstone of
providing culturally competent care. To ade-
quately meet the challenges of health disparities
within communities, careful consideration of
culture must be incorporated in all aspects of
program development, message development,
and implementation.216

Preferred Practices

Community Outreach (6.1)
Preferred Practice 31: Engage communities
to ensure that healthcare providers (individual
and organizational) are aware of current and
changing patient populations and cultural and
communication needs and provide opportuni-
ties to share resources and information.

Specifications:
y Use quantitative and qualitative data

methodologies.

y Engage with local community-based
organizations to access their data.

y Use indirect methods such as public health
and census data.

y Identify key informants and engage them in
interviews and focus groups to learn about
shifting cultural practices of the community.

Preferred Practice 32: Collaborate with the
community to implement programs with clinical
and outreach components to address culturally
diverse populations, health disparities, and
equity in the community.

Specifications:
y Organizations should work closely with a

community advisory board.

y Organizations should collaborate with
community organizations, in particular for
health education programs, where they
can help to raise awareness about local
healthcare services.

y Organizations should partner with the
community on specific programs and draw
on the experiences and resources in the
community to develop training programs,
research projects, and outreach activities.

Preferred Practice 33: Utilize a variety of
formal and informal mechanisms to facilitate
community and patient involvement in
designing, implementing, and evaluating the
effectiveness of cultural competency activities.

Specifications:
y Patients and community representatives

should be actively consulted and involved
in a broad range of service design and
delivery activities; the use of interpreters
and translated materials may enhance such
activities.

y Formal and informal mechanisms should
be utilized, including participation in
governance boards, community advisory
committees, ad hoc advisory groups, and
community meetings, as well as informal
conversations, interviews, and focus groups.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

y Healthcare organizations should collaborate
and consult with community-based organiza-
tions, providers, and leaders for the purposes
of partnering on outreach, building provider
networks, providing service referrals,
and enhancing public relations with the
community being served.

Community Investments (6.3)
Preferred Practice 34: Healthcare professionals
and organizations should engage communities
in building their assets as vehicles for improving
health outcomes.

Specifications:
y Work with the community and organization

decisionmakers to assess gaps in services.

y Engage in community asset mapping.217

y Establish programs and services to
complement existing assets.

y Provide stable funding streams to programs
until they are sustainable through internal
resources.

Community-Based Participatory
Research (6.4)
Practice Statement 35: Use the methodology
of community-based participatory research
when conducting research in the community
as a collaborative approach to research that
equitably involves all stakeholders in the
research process and fosters the unique
strengths that the community brings to the
process.

Specifications:
y Identify key opinion leaders in the community

to assist with decisionmaking involving
research study topics and design.218

y Engage local knowledge and local theory
based on the experience of the people
involved to improve the quality and validity
of the research.219

y Provide resources to and possible
employment opportunities for those in
the communities involved.

y Recognize existing community resources,
and build community capacity to identify
and conduct research.220

Domain 7: Data Collection,
Public Accountability, and
Quality Improvement
The Problem
To reduce disparities, data on race, ethnicity,
and primary language are essential. These
data document where disparities exist, allow
for quality improvement and monitoring
progress, and provide the foundation for
rewarding good performance. The data
currently being captured, however, fall short
of being able to meet these ends. Despite the
obvious benefits of and need for data collection
in these areas, the majority of hospitals, health
plans, and physician practices do not routinely
capture this information. When they do, the
data are often not in a useable form.221 Even
fewer link the data to quality measures or use
them for quality improvement.222 Meaningful
progress to achieve equity in healthcare
quality cannot occur without better data on
race, ethnicity, and primary language.223

The collection of race and ethnicity data
involves many challenges, such as patient
concerns that the data will exacerbate discrimi-
nation and disparities and patient suspicions

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about confidentiality, a need for standardized
race and ethnicity codes and electronic health
records, and a need for consistent data feeds
from multiple providers. There also is concern
that there may be unintended consequences
that could worsen disparities. Recently, however,
The Joint Commission released its Hospitals,
Language, and Culture: A Snapshot of the
Nation study, which identified how the chal-
lenges associated with culture and language
are being addressed at 60 hospitals across
the country. The Joint Commission found a no
“one-size-fits-all” solution, but based on the
data gathered, it states that collecting and
using data are essential to developing and
improving services in healthcare, including
services developed to meet the needs of
diverse patient populations. Moreover, The
Joint Commission specifically calls attention to
this as one of six domains in its framework,
One Size Does Not Fit All: Meeting the Health
Care Needs of Diverse Populations.224

The IOM report Crossing the Quality Chasm
notes that a system is high quality if it provides
care that does not vary because of the personal
characteristics of patients, such as gender,
ethnicity, geographic location, and SES.225

Systemic cultural competency, which includes
processes to monitor and assess the quality
of care and detect disparities by stratifying
measures by race/ethnicity, would lay the
foundation for targeted quality improvement
activities.226 In 2002, IOM released the report,
Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care, which found
that racial and ethnic minorities receive lower
quality of care than their white counterparts,
even after controlling for factors such as
insurance, SES, comorbidities, and stage of

presentation.227 One important—although not
the sole—contributor to these disparities is a
lack of culturally competent care.

A critical component to ensure the linkage
between culturally competent care and
improved outcomes is the collection of
race/ethnicity and primary language data
from patients. We know that the quality of
patient-provider relationships is important—it
affects patients’ adherence to treatment regi-
mens and their satisfaction with care. Despite
the knowledge of its importance to improving
the delivery of culturally competent care and
reducing disparities in the quality of care, the
collection of race/ethnicity and language data
is not systematic or standardized. Stratifying
measures by race/ethnicity and primary
language will enable physicians, hospitals,
healthcare systems, and others to review their
quality information to determine where
disparities exist and act on them. Additionally,
collecting race/ethnicity and primary language
data is an integral step if a healthcare organi-
zation wants to create a report to examine
inequalities in the care provided to patients
from different racial, ethnic, and language
backgrounds.228 Such a report can track
both areas that need improvement and those
that do not and monitor progress toward
eliminating healthcare disparities.

More than basic race, ethnicity, and
language data need to be collected and
integrated into a healthcare provider’s or pro-
fessional’s quality improvement efforts. Current
research suggests that health status is influenced
not only by individual attributes such as genetics
and health behaviors, but also by the physical,
social, and cultural dimensions of a person’s

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

environment.229 Healthcare professionals
and organizations need to understand their
communities, as well as their patient/consumer
populations, to provide quality healthcare serv-
ices. A demographic, cultural, and epidemio-
logical profile of the community and a needs
assessment are tools to help organizations and
professionals understand their communities.
These tools can help providers and policymakers
develop appropriate services and evaluate
access to, and utilization of, those services.

Many people in a service area, especially
individuals with LEP, may be unaware of an
organization’s services and thus never enroll in
its programs. Consequently, it is important to
collect data about potential, as well as current,
patient populations and to use as many data
sources as possible, including sources outside
the organization itself. Because many charac-
teristics of a community change over time, it
also is critical that healthcare organizations
and professionals ensure that data on their
community are up to date.

Preferred Practices

Collection of Patient Cultural
Competency-Related Information (7.1)
Preferred Practice 36: Utilize the Health
Research & Educational Trust (HRET) Disparities
Toolkit 230 to collect patient race/ethnicity and
primary written and spoken language data
from patients in a systematic, uniform manner.

Specifications:
y Use the HRET toolkit as specified. The toolkit

is broken down into sections that outline the
following: who should use the toolkit; why
collect race, ethnicity, and primary language
data; why collect data using a uniform

framework; the nuts and bolts of data
collection; how to ask questions about race,
ethnicity, and primary language; how to use
race, ethnicity, and primary language data
to improve quality of care; how to train staff
to collect this information; how to inform
and engage the community; how to address
the communication access needs of deaf
and hard of hearing populations; available
tools and resources; and answers to
frequently asked questions.

y Organizations should ensure through the use
of policies and procedures that no data are
used for discriminatory purposes.

Preferred Practice 37: Ensure that, at a
minimum, data on an individual patient’s race
and ethnicity (using the Office of Management
and Budget [OMB] categories as modified
by HRET) and primary written and spoken
language are collected in health records and
integrated into the organization’s management
information systems. Periodically update the
language information.

Specifications:
y Use the OMB categories as modified by

HRET231:
• OMB Ethnicity: Hispanic or Latino;

Not Hispanic or Latino
• OMB Race: American Indian or

Alaska Native; Asian; Black or African
American; Native Hawaiian or Other
Pacific Islander; White

• HRET Modifications: Multiracial;
Declined; Unavailable

y Update the information annually.

y Organizations should ensure by policies
and procedures that no data are used for
discriminatory purposes.

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Collection of Community Cultural
Competency-Related Information (7.2)
Preferred Practice 38: Utilize indirect data
collection methodologies (e.g., geocoding,
surname analysis) to characterize the race,
ethnicity, and primary written and spoken
language of a community for service planning
and conducting community-based targeted
interventions.

Specifications:
y Use data to develop and implement

population-level interventions.

y Identify resources for target populations.

y Identify gaps in information and data, and
use direct methods to fill gaps.
• Integrate surname and geocoded address

information when imputing race/ethnicity.
• Use geocoded address information at the

Block Group or Block Level.
• Use the most recent Census Bureau

surname list for surname analysis.232

• Consider Bayesian methods for
integrating surname and geocoded
information.233

• Where possible, use continuous, rather
than categorical, indirect estimates of
race/ethnicity.234

Preferred Practice 39: Maintain a current
demographic, cultural, and epidemiological
profile of the community to accurately plan
for and implement services that respond to the
cultural characteristics of the service area.

Specifications:
y Healthcare organizations should regularly

use a variety of methods and information
sources such as public health data to main-
tain data on racial and ethnic groups in the
service area.

y Data should extend beyond the organization’s
own data, such as marketing, enrollment,
and termination figures, which may provide
an incomplete portrait of the potential
patient population.

y Data sources such as census figures and/or
adjustments, voter registration data, school
enrollment profiles, county and state health
status reports, and data from community
agencies and organizations should be used.

y Quantitative and qualitative methods should
be used to determine cultural factors related
to patient needs, attitudes, behaviors, health
practices, and concerns about using health-
care services as well as the surrounding
community’s resources, assets, and needs.

y Organizations should ensure through
policies and procedures that no data are
used for discriminatory purposes.

y Organizations should ensure through
educational efforts that all patients and the
community are aware of the importance
of the data and of the nondiscriminatory
policies and procedures that are in place.

y After baseline information is obtained, the
data should be updated at least biannually.

Quality Improvement (7.3)
Practice Statement 40: Apply a quality
improvement framework to improve cultural
competency and discover and eliminate
disparities in care using the race, ethnicity,
and primary written and spoken language
information collected by the institution.

Specifications:
y Identify NQF-endorsed performance

measures to collect and use for quality
improvement.

y Based on national benchmarks, set
organizational targets and benchmarks for
performance measures.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

y Utilize performance improvement methodo-
logy and science such as rapid cycle
change and Plan-Do-Study-Act cycles.

Accountability (7.4)
Preferred Practice 41: Publicly report data
for the applicable NQF-endorsed disparities-
sensitive national voluntary consensus standards
for ambulatory care235 stratified by race/
ethnicity and primary written and spoken
language.

Specifications:
y As outlined in the NQF report,236 identify

which quality measures are appropriate
(a subset or all) to stratify and report on for
the population served.

y Utilize the HRET toolkit to collect the
race/ethnicity and primary language data.

Preferred Practice 42: Regularly make avail-
able to the public information about progress
and successful innovations in implementing
culturally competent programs (especially the
NQF-endorsed preferred practices for cultural
competency), and provide public notice in
communities about the availability of this
information. (See also the Leadership domain.)

Specifications:
y Prepare an annual progress report docu-

menting the organization’s progress in
implementing culturally competent practices,
including information on programs, staffing,
and resources.

y Prepare and proactively distribute an
annual progress report documenting the
organization’s progress implementing
culturally competent programs (especially
the NQF-endorsed preferred practices on
cultural competency).

y Ensure that the information provided is
readily accessible and community friendly.

Assessment of Patient Experiences
with Care (7.5)
Preferred Practice 43: Assess and improve
patient- and family-centered communication on
an ongoing basis.

Specifications:
y Use the HRET-specified categories to collect

the race, ethnicity, and primary written and
spoken language of the respondents.

y The design and implementation of communi-
cation initiatives should assess the needs of
patients, families, and staff.

y Data should be used to build support for
initiatives; champions should build support
for new communication initiatives by pre-
senting qualitative and quantitative data on
communication needs and performance.

y Information on model programs should be
collected; site visits to successful programs
should be conducted; and/or published
guides should be consulted.

y At a minimum, annually utilize focus groups
or patient surveys to assess whether patients
and their families find that patient-provider
communication is effective.

Preferred Practice 44: Any surveys created
by or conducted by the organization must
collect race, ethnicity, and primary written
and spoken language, and analysis and
results must be stratified by race, ethnicity,
and primary written and spoken language.

Specifications:
y Survey materials must be translated into and

conducted in threshold languages.

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Documentation of Cross-Cultural
Complaints and Resolutions (7.9)
Preferred Practice 45: Ensure that conflict
and grievance resolution processes are
culturally sensitive and capable of identifying,
preventing, and promptly and equitably
resolving cross-cultural conflicts or complaints
by patients or between organizational staff.

Specifications:
y Policies should be in line with the organiza-

tions other grievance processes, such as
sexual harassment.

y Complaint/grievance mechanisms should
be provided to facilitate communication and
problem resolution.

y Oversight and monitoring of the frequency
and nature of cross-cultural complaints and
grievances and their resolution should occur
and be an integral part of the organization’s
quality assurance program.

y An annual report of all cultural and
language access complaints should be
prepared by the champions and provided
to the leadership.

y Notices should be provided in threshold
languages, at minimum, and potentially in
other languages, about the right of each
patient to file a complaint or grievance.

y A staff member should acknowledge the
receipt of a patient’s grievance orally or in
writing within a timely number of working
days and shall include the name and con-
tact information of the appropriate official.

Areas Recommended for
Further Research
A number of practices evaluated in this project
met the threshold criterion of specificity but
failed to meet one or more of the other criteria.
Based on the evaluations, however, a list of
research areas was developed (Table 2). This
list is not all inclusive, but these areas hold
promise and should be given high priority for
additional research.

Table 2: Areas Recommended for Further Research
Cultural competency research should include the following:
y methods to ascertain the successful implementation of the practices;
y research studies to link the implementation of the practices to improved health outcomes;
y identification of any possible unintended consequences that may arise from the use of the practices;
y use of oral translation and when its use is appropriate;
y unintended consequences around distributing the race/ethnicity of healthcare providers; and
y pharmacogenetics.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

Relationship to Other
NQF-Endorsed Consensus
Standards
This report does not represent the entire scope
of NQF work relevant to cultural competency.
In 2008, NQF identified addressing health-
care disparities as a national imperative and
developed a set of disparities-sensitive measures
that could be used for public reporting, quality,
and disparities improvement at the practice
level.237 Specifically, NQF endorsed a set of
35 performance measures in 8 areas. In addi-
tion, NQF identified a measure of experience
of care that is “disparities sensitive,” compre-
hensive, and broadly applicable in ambulatory
settings. NQF also endorsed a set of disparities-
sensitive measures that addresses community-
level performance. The set includes 14
Agency for Healthcare Research and Quality
Prevention Quality Indicators collected from
hospital discharge data that cover hospitaliza-
tions that might have been avoidable if appro-
priate ambulatory care had been provided.238

NQF’s Improving Healthcare Quality for
Minority Patients: Workshop Summary
explored how measurement and reporting
strategies can be used to improve healthcare
quality for minority patients.239 Additionally, in
May 2003, NQF published Safe Practices for
Better Healthcare, a report (updated in 2006
and 2009)240 documenting 30 NQF-endorsed
practices that should be used universally to
reduce the risk of harm resulting from processes,

systems, or environments of care (with the
2009 update, the practices now number 34).
In December 2003, NQF initiated a project as
a follow-up to this report to identify strategies
for accelerating widespread adoption of the
NQF-endorsed voluntary consensus standard
for informed consent, or Safe Practice 10
(known as Safe Practice 2 in the Safe Practice
2006 update and as Safe Practice 5 in the
2009 update). Safe Practice 10 stood out
among the 30 safe practices because of its
relevance across clinical areas, its focus on
patient-centered care, and its importance to
patients who are particularly vulnerable to
receiving poor-quality care and to being
exposed to medical errors because of
communication barriers. This report on
culturally competent care includes that practice
(Practice 19). A separate NQF publication,
Implementing a National Voluntary Consensus
Standard for Informed Consent: A User’s
Guide for Healthcare Professionals, provides
a concrete tool for assisting healthcare
administrators, providers, interpreters, and
others in implementing and using Safe Practice
10.241 Most recently, NQF released National
Framework and Preferred Practices for
Palliative and Hospice Care, a report that
endorsed two practices about culturally
appropriate end-of-life care.242

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Services in the Nation’s Hospitals, Oakbrook Terrace, IL: The
Joint Commission; 2007. Available at www.jointcommission.org/
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36 The Lewin Group, Indicators of Cultural Competence in
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37 DHHS, Office of Minority Health, National Standards for
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39 Ibid.

National Quality Forum 53

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40 Wilson-Stronks A, Galvez E, Hospitals, Language and Culture:
A Snapshot of the Nation. Exploring Cultural and Linguistic
Services in the Nation’s Hospitals, Oakbrook Terrace, IL: The
Joint Commission; 2007. Available at www.jointcommission.org/
NR/rdonlyres/E64E5E89-5734-4D1D-BB4D-
C4ACD4BF8BD3/0/hlc_paper . Last accessed February
2009.

41 DHHS, Office of Minority Health, National Standards for
Culturally and Linguistically Appropriate Services in Health
Care: Final Report, Washington, DC: Office of Minority Health;
2001. Available at www.nhmamd.org/pdf/
CLASfinalreport . Last accessed January 2009.

42 The Lewin Group, Indicators of Cultural Competence in
Health Care Delivery Organizations: An Organizational
Cultural Competence Assessment Profile, Falls Church, VA:
The Lewin Group; 2002. Available at www.culturally
competentmentalhealthnj.org/docs/2006-12-training/
CC-LewinReport . Last accessed February 2009.

43 Ibid.

44 Hrebiniak LG, Joyce W, Implementing Strategy, New York:
Macmillan; 1984.

45 Wilson-Stronks A, Galvez E, Hospitals, Language and Culture:
A Snapshot of the Nation. Exploring Cultural and Linguistic
Services in the Nation’s Hospitals, Oakbrook Terrace, IL: The
Joint Commission; 2007. Available at www.jointcommission.org/
NR/rdonlyres/E64E5E89-5734-4D1D-BB4D-
C4ACD4BF8BD3/0/hlc_paper . Last accessed February
2009.

46 DHHS, Office of Minority Health, National Standards for
Culturally and Linguistically Appropriate Services in Health
Care: Final Report, Washington, DC: DHHS, Office of Minority
Health; 2001. Available at www.nhmamd.org/pdf/
CLASfinalreport . Last accessed January 2009.

47 The Lewin Group, Indicators of Cultural Competence in
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53 Anderson LM, Scrimshaw SC, Fullilove MT, et al., Culturally
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54 Wilson-Stronks A, Galvez E, Hospitals, Language and Culture:
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75 Campinha-Bacote J, The process of cultural competence in the
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76 Kim-Godwin YS, Clarke PN, Barton L, A model for the
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77 DeRosa N, Kochurka K, Implement culturally competent care
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56 National Quality Forum

National Quality Forum

78 Campinha-Bacote J, The process of cultural competence in the
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79 Kim-Godwin YS, Clarke PN, Barton L, A model for the deliv-
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80 DeRosa N, Kochurka K, Implement culturally competent care
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81 Hobgood C, Sawning S, Bowen J, et al., Teaching culturally
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87 Ibid.

88 Ibid.

89 Ibid.

90 Betancourt JR, Green AR, Carrillo JE, et al., Defining cultural
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91 Brach C, Fraser I, Can cultural competency reduce racial and
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92 Cooper LA, Roter DL, Johnson RL, et al., Patient-centered
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93 The Lewin Group, Indicators of Cultural Competence in
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94 Ngo-Metzger Q, Telfair J, Sorkin DL, et al., Cultural
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95 Betancourt JR, Green AR, Carrillo JE, et al., Defining cultural
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96 Dreachslin JL, Hobby F, Racial and ethnic disparities:
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97 DHHS, Office of Minority Health, National Standards for
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98 Ibid.

99 Anderson LM, Scrimshaw SC, Fullilove MT, et al., Culturally
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100 Dreachslin JL, Hobby F, Racial and ethnic disparities:
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101 DHHS, Office of Minority Health, National Standards for
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103 Ibid.

104 Anderson LM, Scrimshaw SC, Fullilove MT, et al., Culturally
competent healthcare systems: a systematic review, Am J
Prev Med, 2003;24(3):68-79.

105 Wilson-Stronks A, Galvez E, Hospitals, Language and Culture:
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106 Ibid.

107 The Lewin Group, Indicators of Cultural Competence in
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108 Brach C, Fraser I, Can cultural competency reduce racial and
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109 DHHS, Office of Minority Health, National Standards for
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110 The Lewin Group, Indicators of Cultural Competence in
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112 DHHS, Office of Minority Health, National Standards for
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113 The Lewin Group, Indicators of Cultural Competence in
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114 Betancourt JR, Green AR, Carrillo JE, et al., Cultural
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115 Wilson-Stronks A, Galvez E, Hospitals, Language and Culture:
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116 DHHS, Office of Minority Health, National Standards for
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117 The Lewin Group, Indicators of Cultural Competence in
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118 Wilson-Stronks A, Galvez E, Hospitals, Language and Culture:
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127 Ibid.

128 DHHS, Office of Minority Health, National Standards for
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129 Wilson-Stronks A, Galvez E, Hospitals, Language and Culture:
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132 Betancourt JR, Green AR, Carrillo JE, et al., Defining cultural
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135 Ibid.

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145 Ibid.

146 Betancourt JR, Green AR, Carrillo JE, et al., Cultural
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147 DHHS, Office of Minority Health, National Standards for
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148 Wilson-Stronks A, Galvez E, Hospitals, Language, and Culture:
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149 Johnson RL, Saha S, Arbelaez J, et al., Racial and ethnic
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150 Ibid.

151 Wilson-Stronks A, Galvez E, Hospitals, Language, and Culture:
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152 DHHS, Office of Minority Health, National Standards for
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153 Wilson-Stronks A, Lee KK, Cordero CL, et al., One Size Does
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154 Ibid.

155 DHHS, Office of Minority Health, National Standards for
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156 Wilson-Stronks A, Lee KK, Cordero C, et al., One Size Does
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157 Betancourt JR, Green AR, Carrillo JE, et al., Defining cultural
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158 DHHS, Office of Minority Health, National Standards for
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159 Weech-Maldonado R, A Cultural Competency Framework for
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177 American Medical Association (AMA), Ad Hoc Committee
on Health Literacy for the Council of Scientific Affairs, Health
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1999;281(6):552-557.

178 IOM, Health Literacy: A Prescription to End Confusion,
Washington, DC: National Academies Press; 2004.
Available at http://books.nap.edu/html/health_literacy/
reportbrief . Last accessed February 2009.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

179 Brach C, Fraser I, Can cultural competency reduce racial and
ethnic health disparities? a review and conceptual model,
Med Care Res Rev, 2000;57(Suppl 1):187-217.

180 Blackhall LJ, Murphy ST, Frank G, et al., Ethnicity and
attitudes toward patient autonomy, JAMA,
1995;274(10):820-825.

181 Armstrong K, Hughes-Halbert C, Asch DA, Patient preferences
can be misleading as explanations for racial disparities in
health care, Arch Intern Med, 2006;166(9):950-954.

182 Crandall SJ, George G, Marion GS, et al., Applying theory
to the design of cultural competency training for medical
students: a case study, Acad Med, 2003;78(6):588-594.

183 Weech-Maldonado R, A Cultural Competency Framework
for Quality Measurement and Reporting, Washington, DC:
NQF; 2008.

184 Youdelman M, Perkins J, Providing Language Services in
Small Healthcare Provider Settings: Examples from the Field,
New York: The Commonwealth Fund; 2005, pp. 3-14.
Available at www.commonwealthfund.org/publications/
publications_show.htm?doc_id=270667. Last accessed
February 2009.

185 NQF, Implementing a National Voluntary Consensus Standard
for Informed Consent: A User’s Guide for Healthcare
Professionals, Washington, DC: NQF; 2005.

186 National Center for Cultural Competence, Georgetown
University, A Guide to Planning and Implementing Cultural
Competence, Washington, DC: National Center for Cultural
Competence; 2002. Available at www11.georgetown.edu/
research/gucchd/NCCC/documents/ncccorgselfassess .
Last accessed February 2009.

187 Gornick ME, Disparities in Medicare services: potential causes,
plausible explanations and recommendations, Health Care
Financ Rev, 2000;21(4):23-43.

188 Coleman-Miller B, A physician’s perspective on minority
health, Health Care Financ Rev, 2000;21(4):45-56.

189 Williams DR, Rucker TD, Understanding and addressing
racial disparities in health care, Health Care Financ Rev,
2000;21(4):75-90.

190 Paasche-Orlow M, The ethics of cultural competency,
Acad Med, 2004;79(4):347-350.

191 Mead H, Regenstein M, Lara A, The heart of the matter: the
relationship between communities, cardiovascular services
and racial and ethnic gaps in care, Manage Care Inferface,
2007;20(8):22-28.

192 Einbinder LC, Schulman KA, The effect of race on the referral
process for invasive cardiac procedures, Med Care Res Rev,
2000;57(Suppl 1):162-180.

193 NQF, A National Framework and Preferred Practices for
Palliative and Hospice Care Quality, Washington, DC: NQF;
2006, pp. 36-38.

194 Ibid.

195 Cohen JJ, Gabriel BA, Terrell C, The case for diversity in the
health care workforce, Health Aff, 2002;21(5):90-102.

196 Ibid.

197 Johnson RL, Saha S, Arbelaez J, et al., Racial and ethnic
differences in patient perceptions of bias and cultural compe-
tence in health care, J Gen Intern Med, 2004;19(2):101-110.

198 Weech-Maldonado R, A Cultural Competency Framework for
Quality Measurement and Reporting, Washington, DC: NQF;
2008, pp. 5-10.

199 Betancourt JR, Green AR, Carrillo JE, Cultural Competence in
Healthcare: Emerging Frameworks and Practical Approaches,
New York: The Commonwealth Fund; 2002. Available at
www.commonwealthfund.org/publications/publications_
show.htm?doc_id=274805. Last accessed February 2009.

200 Ibid.

201 Cohen JJ, Gabriel BA, Terrell C, The case for diversity in the
health care workforce, Health Aff, 2002;21(5):90-102.

202 Wilson-Stronks A, Galvez E, Hospitals, Language, and Culture:
A Snapshot of the Nation, Oakbrook Terrace, IL: The Joint
Commission; 2008. Available at www.jointcommission.org/
NR/rdonlyres/E64E5E89-5734-4D1D-BB4D-
C4ACD4BF8BD3/0/hlc_paper . Last accessed February
2009.

203 Los Angeles County Department of Health Services, Cultural
and Linguistic Competency Standards, Los Angeles: Los
Angeles County Department of Health Services; 2003,
pp. 15-22.

204 Ibid.

National Quality Forum 61

62 National Quality Forum

National Quality Forum

205 Ibid.

206 Wilson-Stronks A, Galvez E, Hospitals, Language, and
Culture: A Snapshot of the Nation, Oakbrook Terrace, IL:
The Joint Commission; 2008, pp. 60-64. Available at
www.jointcommission.org/NR/rdonlyres/E64E5E89-5734-
4D1D-BB4D-C4ACD4BF8BD3/0/hlc_paper . Last accessed
February 2009.

207 Ibid.

208 Meade CD, Menard J, Martinez D, et al., Impacting health
disparities through community outreach: utilizing the CLEAN
look (Culture, Literacy, Education, Assessment, and
Networking), Cancer Control, 2007;14(1):70-77.

209 Ibid.

210 Ibid.

211 Ibid.

212 Horowitz CR, Arniella A, James S, et al., Community-based
participatory research to reduce health disparities in East and
Central Harlem, Mt Sinai J Med, 2004;71:368-374.

213 Cook WK, Integrating research and action: a systematic
review of community-based participatory research to address
health disparities in environmental and occupational health
in the USA, J Epidemiol Community Health, 2008;62(8):
668-676.

214 Trust for America’s Health, Investments in Disease Prevention
Yield Significant Savings, Stronger Communities. Available at
http://healthyamericans.org/reports/prevention08/. Last
accessed August 2008.

215 Ibid.

216 Wilson-Stronks A, Galvez E, Hospitals, Language, and
Culture: A Snapshot of the Nation, Oakbrook Terrace, IL:
The Joint Commission; 2008, pp. 60-64. Available at
www.jointcommission.org/NR/rdonlyres/E64E5E89-5734-
4D1D-BB4D-C4ACD4BF8BD3/0/hlc_paper . Last accessed
February 2009.

217 Asset Based Community Development Institute, Evanston, IL:
Northwestern University Institute for Policy Research.
Available at www.sesp.northwestern.edu/abcd/. Last accessed
January 2009.

218 Seifer SD, Shore N, Holmes SL, Developing and Sustaining
Community-University Partnerships for Health Research:
Infrastructure Requirements, Seattle, WA: Community-
Campus Partnerships for Health; 2003. Available at
http://depts.washington.edu/ccph/pdf_files/p-nih012903.
pdf. Last accessed February 2009.

219 Ibid.

220 Ibid.

221 National Health Law Program, 51-State Survey of Assessment
of State Laws, Regulations and Practices Affecting the
Collection and Reporting of Racial and Ethnic Data by Health
Insurers and Managed Care Plans, Los Angeles, CA: National
Health Law Program. Available at www.healthlaw.org/
library/item.157293-51State_Survey_of_Assessment_of_
State_Laws_Regulations_and_Practices_Affect. Last accessed
January 2009.

222 Speaking Together: National Language Services Network,
Performance Measures, Washington, DC: George Washington
University Medical Center, School of Public Health and Health
Services. Available at www.speakingtogether.org/measures.
Last accessed October 2008.

223 Expecting Success, Collecting Data on Patient Race, Ethnicity
and Primary Language Is Helping Hospitals Improve the
Quality of Care. Available at www.expectingsuccess.org/
uploads/ESdatacollectionissuebriefFINAL . Last accessed
October 2008.

224 Wilson-Stronks A, Galvez E, Hospitals, Language, and Culture:
A Snapshot of the Nation, Oakbrook Terrace, IL: The Joint
Commission; 2008. Available at www.jointcommission.org/
NR/rdonlyres/E64E5E89-5734-4D1D-BB4D-
C4ACD4BF8BD3/0/hlc_paper . Last accessed February
2009; Wilson-Stronks A, Lee KK, Cordero CL, et al., One Size
Does Not Fit All: Meeting the Health Care Needs of Diverse
Populations, Oakbrook Terrace, IL: The Joint Commission;
2008. Available at www.jointcommission.org/NR/rdonlyres/
88C2C901-6E4E-4570-95D8-B49BD7F756CF/0/
HLCOneSizeFinal . Last accessed February 2009.

225 IOM, Crossing the Quality Chasm: A New Health System for
the 21st Century, Washington, DC: National Academy Press;
2001.

Framework and Preferred Practices for Measuring and Reporting Cultural Competency

226 Betancourt JR, Improving Quality and Achieving Equity: The
Role of Cultural Competence in Reducing Racial and Ethnic
Disparities in Health Care, New York: The Commonwealth
Fund; 2006. Available at www.commonwealthfund.org/
usr_doc/Betancourt_improvingqualityachievingequity_
961 ?section=4039. Last accessed February 2009.

227 IOM, Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care, Washington, DC: National
Academies Press; 2002.

228 Weinick RM, Flaherty K, Bristol SJ, Creating Equity Reports:
A Guide for Hospitals, Princeton, NJ: Robert Wood Johnson
Foundation; 2008. Available at www.rwjf.org/files/research/
050608hospitalequityreport . Last accessed February
2009.

229 Stokols D, Translating social ecological theory into guidelines
for community health promotion, Am J Health Promot,
1996:10(4):282-298.

230 Hasnain-Wynia R, Pierce D, Haque A, et al., Health Research
and Educational Trust Disparities Toolkit, Chicago, IL:
Health Research & Educational Trust. Available at
http://hretdisparities.org. Last accessed September 2008.

231 Office of Management and Budget (OMB), Revisions to
the Standards for the Classification of Federal Data on
Race and Ethnicity, Washington, DC: OMB. Available at
www.whitehouse.gov/omb/fedreg/ombdir15.html.
Last accessed January 2009.

232 Word DL, Coleman CD, Nunziata R, et al., Demographic
Aspects of Surnames from Census 2000. Available at
www.census.gov/genealogy/www/surnames . Last
accessed April 2009.

233 Elliott MN, Fremont A, Morrison PA, et al., A new method for
estimating race/ethnicity and associated disparities where
administrative records lack self-reported race/ethnicity,
Health Serv Res, 2008;(43):1722-1736.

234 Ibid.

235 NQF, National Voluntary Consensus Standards for Ambulatory
Care—Measuring Healthcare Disparities, Washington, DC:
NQF; 2008.

236 Ibid.

237 Ibid.

238 Ibid.

239 NQF, Improving Healthcare Quality for Minority Patients:
Workshop Summary, Washington, DC: NQF; 2002.

240 NQF, Safe Practices for Better Healthcare: A Consensus
Report, Washington, DC: NQF; 2003.

241 NQF, Implementing a National Voluntary Consensus Standard
for Informed Consent: A User’s Guide for Healthcare
Professionals, Washington, DC: NQF; 2005.

242 NQF, National Framework and Preferred Practices for
Palliative and Hospice Care: A Consensus Report, Washington,
DC: NQF; 2006.

National Quality Forum 63

A-1

Appendix A

A Cultural Competency Framework for
Quality Measurement and Reporting

Robert Weech-Maldonado, Ph.D.
Associate Professor

Department of Health Services Research, Management and Policy
University of Florida

This paper has been edited for minimal stylistic consistency. The content and accuracy of
the paper are the responsibility of the author, not the National Quality Forum.

Acknowledgment: The author is grateful to the Cultural Competency Quality Steering
Committee and the National Council for Healthcare Leadership project staff for comments
on earlier drafts of this paper. The author also acknowledges the capable research assistance
of Silvia Menendez, Justin Krueger, and Rohit Pradhan at the University of Florida.

A-1 A-1

A-2

Purpose
The Institute of Medicine1 in its report Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care documents the existence of racial and ethnic disparities in access to
health care, as well as poorer outcomes and health status among racial and ethnic minorities. Among
the strategies advocated for reducing disparities in health care is the provision of “culturally
competent” care.2

The Office of Minority Health’s3 publication of standards for culturally and linguistically appro-
priate services (CLAS) for health care organizations (HCOs) has been a major catalyst in the
development of various frameworks for cultural competence measurement.4,5 Despite these efforts,
consensus on a specific measurement and reporting framework is lacking. In order to advance
the field, national voluntary consensus on critical competencies for measuring and reporting the
quality of culturally competent care is needed. From these competencies, preferred practices and
performance measures can be developed and endorsed.6

The objectives of the paper are to propose: 1) a definition of “cultural competency” in the health
care context; 2) overarching guiding principles in assessing cultural competency; and 3) a frame-
work for measuring cultural competency that can be used across the spectrum of health care
settings.

Culture and Cultural Competency
Culture can be viewed as an “integrated pattern of learned beliefs and behaviors” shared by
individuals of a group that can affect styles of communication, interpersonal relationships, values,
and customs.7 Various sociocultural factors, such as race/ethnicity, nationality, language, gender,
socioeconomic status, physical and mental ability, sexual orientation, and occupation can influence
the cultural background of an individual.

Culture is central in the delivery of health care services, since it can influence patients’ health
beliefs, medical practices, attitudes towards medical care, and levels of trust.3,8 Cultural differences
can ultimately impact how health information is received, understood, and acted upon.9 Clinical
barriers occur when cultural differences are not adequately addressed in health care delivery,
resulting in lower access and quality of care for culturally diverse populations. As such, addressing
cultural differences becomes imperative, and health care organizations are espousing cultural
competency as an organizational strategy.

Brach and Fraser10 have proposed a model whereby cultural competency practices can ultimately
result in a reduction of health disparities. In this model, cultural competency practices can influ-
ence the behavior of clinicians and patients, and bridge cultural gaps. This, in turn, can improve
the likelihood of diverse populations receiving appropriate services and experiencing improved
outcomes and a reduction in health disparities (Figure 1). For example, cultural competency can
reduce barriers in clinician-patient communication, which in turn can improve access to care and
ultimately outcomes of care.9

One of the major organizational barriers for cultural competency is the perceived impact it may
have on costs. However, Brach and Fraser11 have argued the business case for cultural competency.
In their view, HCOs have four interrelated financial incentives for cultural competency. First, by
becoming culturally competent, HCOs can increase their appeal to diverse populations, and
increase their market share. This is particularly critical as the population becomes increasingly
diverse. Second, cultural competence can improve the performance of HCOs in quality measures
that are monitored by private purchasers, which can be particularly important in competitive
markets with a large diverse population. Third, increasingly public purchasers, such as Medicaid
and Medicare, are instituting cultural competency requirements in their contracts. HCOs must
comply with these requirements to maintain their contracts with said public purchasers. Fourth,
cultural competency has the potential to reduce costs by reducing unnecessary diagnostic testing,
inappropriate use of services, and medical errors.

To date, relatively few studies have assessed the extent of cultural competency and diversity
management practices of HCOs in the United States.12,13 Weech-Maldonado and colleagues12 found
that hospitals in Pennsylvania have been relatively inactive with respect to cultural competency
practices, and that equal employment requirements are the main driver of diversity management
policy. The number and scope of cultural competency practices used were not influenced by
organizational or market characteristics. A recent study of Alabama hospitals shows that while
hospitals have taken initial steps to prepare for the diversifying patient population, there is still a
lot more work that needs to be done before they meet the CLAS standards.13

Towards a Definition of Cultural Competency
While the case has been made for cultural competency from a clinical and business standpoint, the
major challenge remaining is how to define and assess cultural competency. Various definitions
exist on cultural competency (Table 1). One distinguishing characteristic of these definitions is the
unit of analysis. While some definitions have focused on the individual or clinician level,14,15 others
have focused on the organizational level.3,6,7,16 Yet other definitions recognize both the individual
and organizational aspects of cultural competency.3,16

A-3

Figure 1: Reducing Health Disparities through the Implementation
of Cultural Competency

Source: Brach and Fraser 10

Diverse
Populations

Cultural
Competency

Appropriate
Services for

Minority
Group

Members

Improved
Outcomes

for Minority
Group

Members

Reduction
of Health

Disparities+

A-4

Table 1. Definitions of Cultural Competence

Author Definition Citation

Betancourt et al. 2002: V 7 “The ability of systems to provide care to patients Curtis et al. 2007

27

with diverse values, beliefs, and behaviors, including Larson 200569

tailoring delivery to meet patients’ social, cultural,
and linguistic needs”

Betancourt et al. 2003: 2978 “Understanding the importance of social and cultural
influences on patients’ health beliefs and behaviors;
considering how these factors interact at multiple
levels of the health care delivery system (e.g., at the
level of structural processes of care or clinical
decision making); and, finally, devising interventions
that take these issues into account to assure quality
health care delivery to diverse patient populations”

Brach and Fraser 2000: 18310 “An ongoing commitment or institutionalization of Curtis et al. 200727

appropriate practice and policies for diverse Dreachslin and
populations” Myers 200728

Weech-Maldonado
et al. 200212

Cooper and Roter “The ability of individuals to establish effective
2003: 55414 interpersonal and working relationships that supersede

cultural differences”

Cross et al. 1989: 1317 “A set of congruent behaviors, attitudes, and policies, Anderson et al. 20039

that come together in a system, agency, or among Brach and Fraser
professionals, and enable effective work in cross- 200010

cultural situations” Brach et al. 200632

Hobgood et al. 200662

Lewin Group 20024

Moxley et al. 200470

Ngo-Metzger et al.
20062

Wilson-Stronks and
Galvez 200735

Zambrana et al.
200471

MCF 200472 “The ability to transform knowledge and cultural
awareness into health and/or psychosocial
interventions that support and sustain healthy client-
system functioning within the appropriate cultural
context”

Kim-Godwin et al. “A complex integration of cultural knowledge,
2001: 92059 cultural awareness or sensitivity, attitudes, cultural

skills, and cultural encounters”

more

A-5

Table 1. Definitions of Cultural Competence
Author Definition Citation

OMH 2001: 53 “Having the capacity to function effectively as an Anderson et al. 20039

individual and an organization within the context of Hobgood et al. 200662

the cultural beliefs, behaviors, and needs presented
by consumers and their communities”

Romeo 2007: 20616 “A learning process that enables individuals and
organizations to function effectively in the midst of
cultural difference”

Sandars and Ewart 2005: 215 “A set of behaviors and attitudes that enable
professionals to work effectively in cross-cultural
situations”

Schim et al. 200773 “A behavioral construct encompassing actions taken
in response to cultural diversity, awareness, and
sensitivity”

Williams 2007: S5574 “A set of academic, interpersonal, and clinical skills
developed to help individuals increase their
understanding of differences and similarities within,
among, and between groups”

All the definitions seem to agree on an ultimate outcome for cultural competency: to improve
health care delivery for diverse populations. However, some of these definitions focus on the
structural aspects of cultural competency, such as having the capacity or ability to address the
health care needs of diverse patient populations,3,7 while others describe cultural competency as
a process.16 Yet other definitions use a combination of structural and process aspects, describing it
as a set of behaviors, attitudes, or both.17

In proposing a definition of cultural competence, we attempted to address both the individual and
organizational aspects of cultural competency as well as the structural and process elements of
cultural competency:

Cultural competency is the ongoing capacity of health care systems, organizations, and
professionals to provide for diverse patient populations high-quality care that is patient-
and family-centered and equitable.

Cultural competency is achieved through policies, learning processes, and structures by which
organizations and individuals develop the attitudes, behaviors, and systems that are needed for
effective cross-cultural interactions, including but not limited to socio-cultural factors such as
race/ethnicity, nationality, language, gender, socioeconomic status (SES), immigrant status,
physical and mental ability, sexual orientation, religion, health literacy, age, and occupation.8

These factors can be conceptualized as cultural group identities. Individuals’ affiliations to cultural
groups are complex, with individual differences based on the group identity profile and strength

A-6

of the group identities.18 For example, a second-generation Hispanic of higher SES will differ from
a recent immigrant Hispanic of lower SES in terms of his or her group identity profile as well as
the strength of the group identities. These differences will affect an individual’s interactions with
the health care system.

High-quality care implies state-of-the-art care based on evidence-based clinical practices.
According to the Institute of Medicine’s (IOM’s)19 “equity” aim for health system improvement,
quality of care should not differ because of socio-cultural factors. Family centeredness implies
respecting the desire of culturally diverse groups to include their family members in health care
decision making.10 The care is patient-centered when clinicians treat each patient as an individual,
within the context of his or her care.20,21 This requires a partnership among clinicians, patients, and
families to ensure that health care decisions take into account patient preferences.

Guiding Principles for Cultural Competency
Guiding principles for measuring and reporting cultural competency quality provide broad themes
and direction that promote standardized measurement and reporting, drive practice improvement
and measure development, and support implementation. The guiding principles are intended to be
overarching and/or cross-cutting all (or multiple) domains of the framework presented in the next
section. There are five principles that guide the development of the proposed cultural competency
framework.

Principle 1. Multi-Level Approach
Cultural competency should be viewed as a multi-level approach with assessments and interventions
needed at the system, provider organization, group, and individual levels.

Cultural competence has generally been viewed as pertinent to individual clinical interactions.
However, this view fails to recognize that “clinicians will become culturally competent only with
the support and/or encouragement of the health systems in which they participate.”10 “Cultural
competence should be considered as much of a function of the organization as it is a result of the
interactions between providers and patients.”

22

Four levels of care can be identified with each requiring a different set of measures of and
interventions for cultural competency: 1) system—as represented by a health care or managed
care entity that oversees a number of owned or affiliated provider organizations; 2 ) provider
organization—the entities that provide direct services to the patient, such as clinics, hospitals,
or nursing homes; 3) group—includes formal departmental and cross-departmental teams; and
4) individual—people involved directly or indirectly in the delivery of care.5,23

Principle 2. Viewed as a Process and Continuum
Cultural competency should be viewed as an ongoing process of organizational transformation in
a continuum from early to later stages of development.

For health care organizations to become more culturally competent they will need to engage in a
change process of organizational transformation. This entails an organizational culture change
from a monoculture, or culture that “accepts only one way of doing things and one set of values

and beliefs” to a pluralistic environment, or an environment that accepts and integrates people
from diverse cultural backgrounds.24

This change process has been described as a continuum from early to later stages of development.
For example, Tirado25 proposes a five-stage model of organizational change: culturally resistant,
culturally unaware, culturally conscious, culturally insightful, and culturally versatile. Similarly,
Dreachslin26 proposes a five-stage change model from affirmative action to valuing diversity:
discovery, assessment, exploration, transformation, and revitalization.

Principle 3. Systems Approach
Successful implementation of cultural competency initiatives to achieve high-quality, culturally
competent care requires an organizational commitment towards a systems approach.

Successful implementation of cultural competency requires an organizational commitment towards
a systems approach.27,28 In this approach, the HCO is viewed as a system comprised of interrelated
and interdependent subsystems, such as patient care, ancillary services, professional staff, financial,
informational, physical, and administrative subsystems.29

Related to systems thinking is the open systems perspective that views organizations interacting
with their environment to secure resources, process them, and produce some type of output. To
survive, it is critical that organizations respond to the demands of their environment to ensure a
continuous inflow of resources.30 For HCOs, the community is the major resource supplier.
Therefore, HCOs have to adapt to the changing community needs to ensure their survival.

Cultural competency should not be conceived as a stand alone, point-in-time effort pertinent only
to clinical interactions. Rather, HCOs should strive towards a systems approach where cultural
competency practices are integrated throughout their management and clinical sub-systems.
Furthermore, HCOs should engage their communities in meaningful participation in the organiza-
tion’s decision-making and power structures.

Principle 4. Diversity Management
Addressing both organizational and clinical aspects in managing diversity and the needs of both a
diverse workforce and patient population are important factors in culturally competent care.

The cultural competency and diversity management literatures have had different focuses with
respect to diversity issues. The cultural competency literature has had a clinical orientation with a
focus on patient-clinician interactions, while the diversity management literature has had an orga-
nizational orientation with a focus on workforce issues. However, these differences are becoming
increasingly less distinct as both camps agree on the importance of both to cultural competency.12

For example, it is increasingly recognized that organizations need strategies aimed at recruiting
and retaining a diverse workforce, as well as staff training and development in cross-cultural
communication skills to enhance cultural competency.

A-7

A-8

Principle 5. Continuous Improvement
Cultural competency should not be viewed as an endpoint but rather organizations should strive
for continuous improvement.31

Continuous improvement in cultural competency represents an ongoing process whereby
organizations: 1) determine cultural competency goals in the context of its strategic plan; 2) assess
individual, group, and organizational baseline performance to determine gaps in performance;
3) develop interventions to close the gaps in performance; and 4) reassess performance to
determine the effectiveness of the interventions. For example, in designing cultural competency
training, the organization should determine goals for its training in the context of its strategic
plan, measure current performance against needs, design training to address the gap, implement
the training, assess training effectiveness, and strive for continuous improvement.27

Framework for Measuring and
Reporting Cultural Competency Quality
Standardized measurement and reporting of cultural competency requires identification of a com-
prehensive framework that delineates the domains and sub-domains that comprise high-quality,
culturally competent care. The framework consists of seven domains of cultural competency and
their respective sub-domains (Table 2). From this framework, preferred practices can be identified
and/or mapped to, and from those practices, measures can be developed.

Domains
Seven primary domains are recommended:

1. Leadership recognizes that organizational leaders, including clinical leaders, administrative
leaders, and the Board of Trustees, play an essential role in developing and implementing
cultural competency activities, in setting organizational policy and strategy, and in monitoring
organizational performance.

2. Integration into Management Systems and Operations focuses on whether cultural
competency is integrated throughout all management practices of the organization.

3. Patient-Provider Communication addresses all communication between the patient and
clinicians as well as support staff.

4. Care Delivery and Supporting Mechanisms encompasses the delivery of care, the physical
environment of where the care is delivered, and links to supportive services and providers.

5. Workforce Diversity and Training can be viewed as a means to providing more effective
services for culturally diverse populations via human resource proactive recruitment and
retention strategies to ensure diversity at all levels of the organization, and it also relates to
whether training and development activities include state-of-the-art content in cultural
competency and reflect organizational commitment towards cultural competency.

6. Community Engagement refers to active outreach, as well as community inclusion and
partnership in organizational decision making.

A-9

Table 2. Framework for Measurement and Reporting of Cultural Competency

Domain Sub-domains

Leadership Commitment to Diversity
Organizational Culture
Leadership Diversity
Dedicated Staff and Resources
Policies
Training and Development

Integration into Management Systems Strategic Planning
and Operations Performance Evaluation

Reward Systems
Service Planning
Marketing
Public Relations

Patient-Provider Communication Interpreter Services
Translation Services
Health Literacy Strategies
Knowledge of Culture and Social Context
Cultural Awareness
Cross-Cultural Communication Skills
Family Centeredness

Care Delivery and Supporting Physical Environment
Mechanisms Assessment Tools

Coordination of Care
Linkages with Alternative Medicine Providers
Linkages with Community Based Organizations
Health Information Technology

Workforce Diversity and Training Recruitment
Retention
Training Commitment
Training Content

Community Engagement Community Outreach
Community-Based Participatory Research
Community Representation in Organizational Decision Making
Community Investments

Data Collection, Public Accountability, Collection of Patient Cultural Competence-Related Information
and Quality Improvement Information Assessment of Patient Experiences with Care

Documentation of Cross-Cultural Complaints and Resolutions
Documentation of Cultural Competency Practices
Collection of Community Cultural Competence-Related
Performance Management Systems
Self-assessments of Cultural Competence
Quality Improvement

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7. Data Collection, Public Accountability, and Quality Improvement means whether the
organization collects data necessary to assess its cultural competency, whether it performs
routine self-assessments in this regard, and whether it integrates cultural competency into its
public accountability and quality improvement activities.

Sub-domains
Each of the seven proposed domains also includes specific sub-domains that further articulate the
core competencies of high-quality, culturally competent care, as follows:

1. Leadership
a. Commitment to Diversity—cultural competency activities are most effective when the

organization’s governing board and top management embrace cultural competence and
communicates this support throughout the organization.32,33

b. Organizational Culture—a culture that is inclusive and values cultural differences.
Organizational leaders are instrumental in setting organizational culture.34 Inclusive signifies
that the organization’s decision-making processes include diverse points of views from within
and outside the organization. When an organization values diversity it is shown through its
practices, structures, and policies.

c. Leadership Diversity—leadership at all levels of the organization, including the Board of
Trustees, reflects the community diversity.4 Leadership diversity increases the likelihood that
the needs of a diverse workforce and patient population are taken into account in organiza-
tional decision-making processes.9 However, minorities have traditionally faced barriers, or a
“glass ceiling” effect, that have excluded them from upper management positions.18 As such,
HCOs need proactive human resource strategies aimed at diversifying the leadership ranks
and breaking the glass ceiling.

d. Dedicated Staff and Resources—an organization shows its commitment to cultural competen-
cy by dedicating resources and designating staff for cultural competency activities. Dedicated
resources can be shown by budgeting resources for cultural competency activities.4,35

Dedicated staff can include an executive-level staff member, department, or office that focuses
on multicultural and/or linguistic issues. This can be instrumental in coordinating organization-
wide initiatives and monitoring progress towards cultural competency goals.32,35

e. Policies—formal policies that address cultural competency issues, such as recruitment and
retention of a diverse workforce, language services, and training and development.4,35 Policies
“express an organization’s intentions and provide a blueprint for action.”36 These internal
policies should be in conformity with external regulatory and statutory policies.

f. Training and Development—training and development of leaders at all levels of the organiza-
tion, including the Board of Trustees, on cultural competency issues.4 Leadership participation
in training and development sends a signal to organizational members of its commitment to
cultural competency.

2. Integration into Management Systems and Operations

a. Strategic Planning—the strategic planning process includes environmental scanning,
asset and needs assessment of the communities served, and formulation of goals related to
cultural competency.3 Strategic goals reflect the organizational priorities for resource use and
deployment.

b. Performance Evaluation—job descriptions and performance evaluation systems include
criteria related to cultural competency.3,4 This evaluation process should include assessments
of patient and family experiences with care. This results in accountability for meeting cultural
competency goals.

c. Reward Systems—managers and staff are rewarded for meeting cultural competency goals.4

Incentives help align the organizational members’ goals with those of the organization.
Thorndike’s law of effect states that behavior or performance that is reinforced tends to be
repeated.37

d. Service Planning—organizations design their services taking into account the needs of their
diverse patient populations. This includes all elements of the health care encounter from
admission to discharge with the ultimate goal of improving access to care for all patients.8

Examples include expanding clinical hours to accommodate community work patterns,
adapting to ethnic or religious dietary preferences, and allowing for large families visiting or
staying with hospitalized patients.8,35

e. Marketing—organizations promote and market their services through a variety of media that
reaches out to diverse populations, including ethnic newspapers, television news programs,
and radio stations.35 Marketing also should emphasize the availability of language services,
such as interpretation and translation services. A related concept is that of social marketing
where HCOs use marketing principles to design a social-change strategy aimed at reducing
high-risk behaviors or encouraging healthy behaviors.38,39 An example of social marketing is
using the media for a public health campaign to reduce smoking.

f. Public Relations—raise public awareness of cultural competency activities and progress
in meeting goals.3,4 This can include a statistical annual report on patient demographics,
interpreter use and availability, translated materials, staff training in cultural competency, and
survey results of patient experiences with care. This can serve as a marketing tool while
enhancing the organization’s image among diverse communities.

3. Patient-Provider Communication

a. Interpreter Services—high-quality interpreter services are needed at all points of patient
contact to improve provider and staff communication with patients of limited English profi-
ciency. Accurate communication increases the likelihood of receiving appropriate care.3,9,35

Language concordant encounters have better communication, interpersonal processes, and
outcomes than language discordant encounters.40-44 However, the limited supply of bilingual
providers has led health care organizations to use interpreter services to bridge language
gaps. When evaluating the quality of interpreter services, it is important to distinguish
between professional and ad-hoc interpreters.2 Ad-hoc interpreters are “individuals whose
primary job function in the health care setting is something other than interpretation and
includes the patient’s family members, friends, clinic staff, or even fellow patients.”45 On the
other hand, professional interpreters are “those individuals whose sole function in the health

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care setting is to interpret.”45 Prior research has shown the effectiveness of professional inter-
preters compared to ad-hoc interpreters.46-48 Professional interpreter services may be in-person
or remote. Remote interpreter services include telephone language lines, video links, and
other remote systems. Regardless of the type of interpreter used, interpreters should have
proficiency in both languages, mastery of medical terminology in both languages, memory
skills, ability to negotiate a three-way conversation, and basic knowledge of cultural aspects
that can influence health. Bilingual providers should be proficient in the target language,
including knowledge of medical terminology.2

b. Translation Services—patient-related written materials are translated into the most common
languages of the patient population.3,4 Examples of relevant patient-related materials include
applications, consent forms, preventive and treatment instructions, and patient education
materials. Translated materials should be evaluated for linguistic and cultural appropriateness
with respect to both content and context.49 Linguistically appropriate translated materials are
conceptually and technically equivalent to the source language. Technical equivalence refers
to similarity in grammar and syntax, while conceptual equivalence refers to the absence of
differences in meaning and content between the source and translated documents. Weidmer
et al. have proposed a translation process that involves: 1) obtaining two independent forward
translations; 2) conducting a review of translation by a separate bilingual reviewer; and
3) reconciling translations by committee (forward translators and bilingual reviewer) consen-
sus.50 Culturally appropriate translated materials reflect the cultural assumptions, norms,
values, and expectations of the target population.51 Qualitative methods, such as focus groups
and cognitive interviews, are particularly useful in assessing the cultural appropriateness of
translated materials.49

c. Health Literacy Strategies—addressing the literacy needs of the patient in both oral and writ-
ten communication.2 Healthy People 2010 defines health literacy as the “degree to which
individuals can obtain, process, and understand the basic health information and services they
need to make appropriate health decisions.”52 People with low health literacy tend to have
more problems with both written and oral communication.53 Several strategies have been
suggested for health care professionals to improve oral and written communication with low
literacy patients:54-56 1) avoid use of medical jargon, and instead use commonly understood
words; 2) use audiovisual aids to supplement oral and written instructions; 3) include interac-
tive instructions by making patients do, write, say, or show something to demonstrate their
understanding (teach back method); 4) write materials at a sixth-grade level or lower; and 5)
pretest materials to evaluate whether materials are suitable for the intended audience.

d. Knowledge of Culture and Social Context—having the knowledge base of cultural groups
with respect to traditional healing practices, health-related beliefs and cultural values, disease
incidence, prevalence and outcomes, as well as health disparities.57-60 This knowledge should
include also an awareness of the historical context that may explain the way different groups
interact with the health care system.8 One example is the relationship between the Tuskegee
Syphilis Study and mistrust of health care professionals among African Americans.
However, care must be exercised that this cultural knowledge does not lead to or reinforce
stereotyping.8 Rather this knowledge should be used in the context of patient-centered care
and effective cross-cultural communication skills.61

e. Cultural Awareness—self-examination and exploration of one’s own cultural background.
This includes an awareness of our own assumptions, biases, stereotypes, and prejudices with
respect to individuals from other cultures.58-60

f. Cross-Cultural Communication Skills—this includes skills to obtain culturally relevant data,
such as those used in conducting cultural assessments and culturally based physical assess-
ments.58-60,62 It also includes skills needed in “identifying and negotiating different styles of
communication, decision-making preferences, roles of family, sexual and gender issues, and
issues of mistrust, prejudice, and racism.”8 Patient-centered cross-cultural communication
makes the patient a primary source of cultural knowledge and an active participant in the
patient-doctor negotiation.

g. Family Centeredness—respecting the desire of culturally diverse groups to include their
family members in health care decision making.10

4. Care Delivery and Supporting Mechanisms

a. Physical Environment—this includes culturally sensitive design and architecture, physical
environments, where the décor, artwork, posters, and literature reflects the diversity of the
service area.4 It also includes appropriate signage in the major languages spoken in the
service area.3

b. Assessment Tools—use of tools to elicit culturally relevant information on health beliefs,
behaviors, and practices.4 These data can be used to assist with establishing a physical
environment and care delivery that are culturally appropriate for the community served.

c. Coordination of Care—includes documenting and tracking referrals to other health care
services in the continuum of care (from ambulatory to long-term care), and ensuring that
information on patients’ cultural and linguistic needs is shared with other health care
providers. Coordination of care includes managing the transition back to home, nursing
home, or other institutional care, and supporting palliative and end of life care.

d. Linkages with Alternative Medicine Providers—identifying patients’ use of alternative
providers and coordinating with these providers to augment allopathic treatments and avoid
complications due to incompatible therapies.10

e. Linkages with Community-Based Organizations—understanding and addressing the context
of the patient (e.g., socioeconomic status, supports/stressors, environmental hazards) as an
important element of cultural competence.4,8 It is important to identify community-based
organizations, such as human, social service, and religious organizations, and coordinate with
them to assist with care delivery.

f. Health Information Technology—new information technologies, such as electronic and
personal medical records, should be used to enhance and promote the delivery of culturally
competent care.

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5. Workforce Diversity and Training

a. Recruitment—human resource practices aimed at diversifying the workforce at all levels of
the organization.4 Racial/ethnic and language concordance between patient and provider has
been associated with better patient experiences with care and satisfaction.2,8 However, the
current demographics of the health professions do not correspond to the composition of the
general workforce. For example, while African Americans and Hispanics account for about
25 percent of the workforce, fewer than 12 percent of physicians and therapists, and only 15
percent of registered nurses are from these two racial/ethnic groups.36 This calls for proactive
recruitment strategies that will result in a more diverse applicant pool. As such, organizations
“need to find alternatives to generic newspaper advertisements, search firms, and other main-
stream recruiting methods. Community-based and national health organizations and networks
as well as publications and search firms that target diverse populations may provide better
channels for recruiting and advertising vacancies.”3 Furthermore, organizational efforts aimed
at improving the diversity of the workforce pipeline are needed. This may include partner-
ships with local elementary and secondary schools, particularly those with a high percentage
of racial/ethnic minorities, to increase their interest in the health care professions.

b. Retention—organizational efforts need to go beyond recruitment strategies and include
retention strategies. Otherwise organizations can become a “revolving door” for diverse
employees, as they leave the organization in pursuit of better opportunities or a more
welcoming environment. Retention strategies include efforts to create a welcoming climate
for diverse populations, identifying barriers that prevent employees from achieving their full
potential, and providing equitable promotional opportunities.3,9 Formal mentoring programs,
professional development and training, work-life balance and flexible benefits, and affinity
groups are among the human resource retention strategies that can be used.

36

c. Training Commitment—organizations need to ensure that managers and staff at all levels of
the organization receive appropriate and ongoing training in cultural competency.3,4

d. Training Content—staff training curriculum should emphasize the knowledge and skills as
outlined under the 1) patient-provider communication and the 2) care delivery and supporting
domains.4,9 In addition, staff training should include strategies to assist a diverse staff with
relating to each other. Leadership training should include content from all seven domains of
cultural competence. Cultural competency training can be delivered as a stand-alone program
or it can be integrated into other training programs. Formal training can be complemented
with less formal activities that develop staff knowledge about cultures and languages in their
hospital, such as cultural fairs and reading clubs focused on specific cultures or languages.35

These trainings should be conducted by qualified staff that are trained in cultural competence,
and should be periodically updated and repeated. The trainings should be assessed for
effectiveness and relevance in meeting the cultural needs of patients.

6. Community Engagement

a. Community Outreach—this includes collaborative relationships and partnerships with
community entities to understand and address the cultural and linguistic needs of the
communities served.35,63 It may also include liaisons, such as community health workers
where members of minority communities are used to reach out to those communities.4,10 For
example, community health workers that are trained to teach others with the same chronic
conditions about disease self-management.

b. Community-Based Participatory Research—actively engage in community-based participatory
research (CBPR), which has been defined as a “collaborative research approach that is
designed to ensure and establish structures for participation by communities affected by the
issue being studied, representatives of organizations, and researchers in all aspects of the
research process to improve health and well-being through taking action, including social
change.”64 By engaging in CBPR, HCOs enable the generation of actionable knowledge that
can be used to address the most pressing health needs of the populations served.65

c. Community Representation in Organizational Decision Making—using formal and informal
mechanisms for community involvement, such as community advisory groups or committees
in service planning and implementation.3,4

d. Community Investments—organizations should invest in both the infrastructure and human
capital of the communities served, and should take into account the community assets in its
outreach, education, and information gathering activities.

7. Data Collection, Public Accountability, and Quality Improvement

a. Collection of Patient Cultural Competence-Related Information—mechanisms for collecting
data on cultural subgroups, such as race/ethnicity, language preferences, education, and
income of patients; and integrating these data into the information systems.3,4 These data are
important for strategic and service planning and can be used to monitor health care disparities
as well as for quality improvement.7 The Joint Commission now requires collection of
patients’ language and communication needs in the patient record.35

b. Assessment of Patients’ Experiences with Care—assess patients’ experiences with care in
their own language using qualitative and quantitative methods. Patients’ assessments of care
are critical because they capture firsthand experiences as patients interact with the health care
system. The Consumer Assessments of Healthcare Providers and Systems (CAHPS) is a set
of standardized survey instruments that assess patient experiences with care across provider
settings. Prior research using CAHPS data has shown racial/ethnic and language differences
in patients’ experiences with care.66,67 Focus groups and personal interviews are qualitative
methods that can complement quantitative assessments, such as CAHPS, by providing more
in-depth information on the observed cultural differences in patient experiences with care.
These data can be used for quality improvement purposes.7

c. Documentation of Cross-Cultural Complaints and Resolutions—having in place mechanisms
to identify and resolve cross-cultural conflicts or complaints by patients.3 Individuals from
diverse backgrounds are more vulnerable to face experiences where their cultural differences
are not accommodated or respected by the HCO. Some of the mechanisms that HCOs can
adopt to identify and resolve cross-cultural conflicts are: “providing cultural competence
training to staff who handle complaints and grievances or other legal or ethical conflict
issues; providing notice in other languages about the right of each patient/consumer to file a
complaint or grievance; providing the contact name and number of the individual responsible
for the disposition of a grievance; and offering ombudsperson services.”3

d. Documentation of Cultural Competency Practices—mechanisms to document the delivery of
culturally competent care services, such as the provision and timeliness of language services,
workforce diversity, and referrals to alternative medicine providers and community-based
organizations. This information is important for on-going self-assessments of cultural
competency, as well as for public reporting of such activities.

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e. Collection of Community Cultural Competence-Related Information—this includes maintain-
ing a current demographic, cultural, socioeconomic, and epidemiological profile and needs
assessment of the communities served and using the data for strategic planning purposes,
quality improvement, and public reporting initiatives.3,4,35

f. Performance Management Systems—include cultural competence-related measures in
the organizational performance management systems, such as balanced score cards, organiza-
tional climate surveys, adverse events reports, and outcomes-based evaluations.3,35 Examples
of metrics that can be incorporated are patient and human resource outcomes for different
cultural groups. Including these measures in performance management systems elevates their
importance for the institution.28

g. Self-assessments of Cultural Competence—organizations should conduct ongoing self-
assessments of their progress in meeting cultural competence goals.3 Assessments are needed
at all four levels of care: system, provider organization, group, and individual.8 System and
provider organizational-level assessments provide a picture of the organization’s readiness
towards cultural competency by examining its structures, policies, and practices. Group-level
assessments can provide a gauge of organizational culture and climate. Individual-level
assessments can assess cultural competency and cross-cultural skills at the individual level.

h. Quality Improvement—organizations integrate cultural competence into their quality
improvement (QI) activities. QI can be viewed as an organization-wide approach to planning
and implementing continuous improvement in performance. As such, QI “emphasizes contin-
uous examination and improvement of work processes by teams of organizational members
trained in basic statistical techniques and problem solving tools and empowered to make
decisions based on the analysis of data.”68 Health care organizations can use QI activities to
address health disparities in access, outcomes, or patient experiences with care.

Conclusion
The Office of Minority Health’s CLAS standards have been a major catalyst in the development
of various frameworks for cultural competence measurement. Despite these efforts, consensus
on a specific measurement and reporting framework has been lacking. Standardized measurement
and reporting of cultural competency requires identification of a comprehensive framework that
delineates the core competencies that comprise high-quality, culturally competent care. This paper
achieved three major goals. First, we proposed a definition of cultural competence that addresses
both the individual and organizational aspects of cultural competency, as well as the structural
and process elements of cultural competency in health care. Second, we established five guiding
principles that are intended to be overarching and/or cross-cutting all (or multiple) domains of the
proposed framework. Finally, we proposed a framework consisting of seven core competencies
or domains of cultural competency: 1) leadership; 2) integration into management systems and
operations; 3) patient-provider communication; 4) care delivery and supporting mechanisms;
5) workforce diversity and training; 6) community engagement; and 7) data collection, public
accountability, and quality improvement. Each of the seven proposed domains also includes
specific sub-domains that further articulate the core competencies of high-quality, culturally
competent care. From this framework, preferred practices and performance measures can be
developed and endorsed by the National Quality Forum.

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www.asha.org/about/publications/leaderonline/archives/2004/040413/f040413b1.htm. Last accessed October 2008.

71. Zambrana RE, Molnar C, Munoz HB, et al., Cultural competency as it intersects with racial/ethnic, linguistic, and class
disparities in managed healthcare organizations, Am J Manag Care, 2004(Special Issue):SPO37-APO44.

72. Ministry for Children and Families, Cultural Competency Assessment Tool, Vancouver, Canada: Vancouver Ethnocultural
Advisory Committee of Ministry for Children and Families; 2004.

73. Schim SM, Doorenbos A, Benkert R, et al., Culturally congruent care: Putting the puzzle together, J Transcult Nurs,
2007;18(2):103-110.

74. Williams RA, Cultural diversity, health care disparities, and cultural competency in American medicine, J Am Acad Orthop,
2007;15(1):S52-S58.

A-19

Community-based participatory research (CBPR)—A collaborative approach to
research that combines methods of inquiry with community capacity-building strategies to
bridge the gap between knowledge produced through research and what is practiced in
communities to improve health. Interest is growing rapidly in having academic institutions,
health agencies, and communities form research partnerships; however, few agreed-upon
guidelines describe how to develop or evaluate CBPR proposals or what resources are
required to promote successful collaborative research efforts.

Health professional—Physicians, administrators, nurses, physical and occupational
therapists, linguistic services providers, psychologist social workers, and others who provide
care to a patient.

High-quality healthcare—Healthcare that is delivered in a safe, effective, patient-centered,
timely, efficient, and equitable manner and that is state of the art and evidence based.

Leadership—In reference to Domain 1, it refers to leadership by the board of directors,
trustees, and C-suite level and senior managers.

Patient—The individual recipient of care—that is, the patient, client, legal surrogate,
or person.

Primary written and spoken language—The self-selected language the patient wishes
to use to communicate with his or her healthcare provider.

Threshold language—Title 9 of the California Code of Regulations, Section 1810.410,
addresses the Cultural and Linguistic Requirements of the public mental health systems in
California. Section 1810.410(f) defines threshold language as a primary language spoken
by 3,000 people, or 5 percent of the beneficiary population, whichever is lower in an
identified geographic area. However, state requirements may vary, so state requirements
should be followed.

National Quality Forum B-1

A Comprehensive Framework and Preferred Practices
for Measuring and Reporting Cultural Competency:
A Consensus Report

Appendix B
Glossary

B-1

A Comprehensive Framework and Preferred Practices
for Measuring and Reporting Cultural Competency:
A Consensus Report

Appendix C
Implementation Examples Cross-Walked
to Practices

National Quality Forum C-1

National Quality Forum C-2

Appendix C— Implementation Examples Cross-Walked to Practices

PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

more
Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

Leadership—Organizational Culture

Leadership—Commitment to Serving
a Diverse Population

Leadership—Policies

y At WakeMed Health and Hospitals, in Raleigh, North Carolina, 70 percent of annual employee
evaluation components focus on the demonstration of technical skills, and 30 percent focus on
meeting organizational standards, including the commitment to understanding patients’ cultures
and improving communication skills.

y Several hospitals in Illinois, North Carolina, New York, and Washington have written policies that
strongly discourage or prohibit a patient’s family members or friends from being used as medical
interpreters (Harborview Medical Center, Sherman Hospital, Woodhull Medical and Mental Health
Center, and WakeMed Health and Hospitals).

y Three Iowa Health System sites have policies mandating that new patient education materials must
be approved by patient education committees (Finley Hospital, Iowa Home Health Care, and Trinity
Regional Medical Center Fort Dodge).

y The University of Virginia Health System has a “policy on policies” that provides guidance for clearly
writing, classifying, and disseminating new policies.

y Cambridge Health Alliance in Boston is explicit about services offered to address cultural
competency by meeting the needs of patients in its code of ethics. See www.cha.harvard.edu/
aboutus/ethical_guidelines.shtml.

y The Los Angeles County Department of Health Services has integrated cultural and linguistic
policies into a comprehensive plan that includes needs assessment, training, monitoring, and
language service provision.1

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2
3
6

Identify and develop informed
and committed champions of
cultural competency throughout
the organization in order to
focus efforts around providing
culturally competent care.

Ensure that a commitment to
culturally competent care is
reflected in the vision, goals,
and mission of the organization,
and couple this with an
actionable plan.

Commit to cultural competency
through systemwide approaches
that are articulated through
written policies, practices,
procedures, and programs.

National Quality Forum C-3

Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

Leadership—
Training and Development

Integration into Management Systems
and Operations—Service Planning

y The Disparities Solutions Center of Massachusetts General Hospital has developed and implements
the Disparities Leadership Program, a year-long leadership program designed to tackle racial and
ethnic disparities in healthcare. Components of this program include providing specific skills and
knowledge for leaders in healthcare.2

y The Migrant-Friendly Hospitals, a European project sponsored by the European Commission and
Directorate General for Health and Consumers, has developed cultural competency training for
hospital staff and leaders that focuses on cultural awareness, recognizing one’s own prejudices, and
developing the relevant skills needed to provide care for diverse populations.3

y Kids Connections in Louisville, Colorado, employs eight service coordinators, three of whom are
bilingual. All eligible families are assigned a service coordinator. The organization matches limited
English proficiency (LEP) families with bilingual coordinators. The program provides services through
contracts with early intervention therapists and collaborates with health departments, hospitals,
doctors, child care providers, school districts, and other community services. The service coordinators
work in partnership with other providers to ensure that children and families receive appropriate
services.

y As suggested by the Department of Health and Human Services (DHHS) Office for Civil Rights, the
Asian Pacific Health Care Venture (APHCV) has developed a written language access plan that out-
lines the practices APHCV employees must follow to comply with Title VI of the Civil Rights Act and
Office for Civil Rights guidance. Four key areas are discussed: assessment of needs, development of
policies and procedures, training of staff, and vigilant monitoring. Partial funding for the manual
was provided by DHHS’ Bureau of Primary Health Care. It has been distributed to all APHCV
employees and is periodically reviewed and revised.

y Model policies and procedures were developed to address issues of language access related to immi-
grants and visitors to the United States who are protected under civil rights law from discrimination
based on national origin; they do not address access issues related to disability. Although based
primarily on California public hospitals, they are adaptable to the entire U.S. hospital industry
(state or local laws would need to be referenced, however).4

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7
9

Actively seek strategies to
improve the knowledge and
skills that are needed to
address cultural competency in
the organization.

Implement language access
planning in any area where
care is delivered.

National Quality Forum C-4

Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

Integration into Management Systems
and Operations—Service Planning
(continued)

Integration into Management Systems
and Operations—Reward Systems

y An Internet-based database designed to assist physicians and others in providing improved language
access and culturally competent healthcare has been developed by the Medical Leadership Council
on Cultural Proficiency, located in California. Free to the public, the database includes contact
information for interpreters, nonprofit organizations, hospitals, public health departments, and
others that provide health information and services in languages other than English. Users can
search for listings by county, by language, or by type of service. The database helps users quickly
find interpreters, materials about how to provide culturally competent care, information in several
languages about specific diseases and healthy practices, and county-specific contacts for identifying
additional sources of assistance.5

y The U.S. Congress legislated the Baldrige Award in 1987, and the first awards were presented in
1988. Each year, applicants prepare detailed assessments of their management systems; their
applications respond to the Criteria for Performance Excellence, which are built upon a set of 11
interrelated core values and concepts. The seven criteria categories provide a systems perspective
of the elements essential to achieving performance excellence (see www.quality.nist.gov).

y The National Committee for Quality Assurance (NCQA) established the Recognizing Innovation in
Multicultural Health Care Award program to recognize innovative programs provided by specific
health plans for identifying and reducing care disparities related to culturally and linguistically
appropriate services (CLAS); the Innovative Practices report highlights the award-winning plans.
Health plans must fill out an application and describe their programs in detail, including any
measurable outcomes. NCQA staff members convene a panel of experts to evaluate the initiatives
using standardized forms based on six criteria: rationale or conceptual framework; innovative/
creative approach to reducing healthcare disparities; evidence of impact on services or outcomes;
sustainability; transferability; and organizational integration and leadership.

more

10 Implement reward and
recognition programs to
recognize specific individuals,
initiatives, and programs within
the organization that promote
cultural competency.

National Quality Forum C-5

Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

Integration into Management Systems
and Operations—Marketing and
Public Relations

Patient-Provider Communication—
Language Access

y Kaiser Permanente has launched an electronic media campaign to promote preventive healthcare
and healthy living.6 This campaign includes ads as well as a user-friendly interactive website that is
a source of information and resources.

y Health Net of California has partnered with Mexican healthcare providers to form a cross-border
healthcare plan, allowing Mexican immigrants and Californians to receive the same quality of care
services.7

y North DeKalb in Chamblee, Georgia, a satellite clinic of Grady Hospital, employs one full-time
interpreter, two bilingual physicians, and a bilingual support staff member. The full-time interpreter
provides most of the interpretation services. In her absence, physicians occasionally use bilingual
medical staff, mainly nurses, for interpretation.

y The cultural and linguistic services department of L.A. Care periodically surveys participating
providers and monitors developments and innovations nationally and in the research literature.
Using this information, as well as its own research studies and reports, L.A. Care is constantly
developing language services and information for its participating providers.

y At Planned Parenthood of Pennsylvania in York, Pennsylvania, bilingual staff members generally
answer the phone. If not, when a LEP patient calls, the individual answering the phone immediately
asks for assistance from a bilingual staff member. LEP patients’ language needs are noted when
their appointments are scheduled to ensure that a bilingual staff member will be available to interpret.

y The Washoe County in Reno, Nevada, Family Planning Program employs only bilingual Spanish-
speaking support staff for its telephone language line. Every day, four to six bilingual staff members
are onsite. One of the nurse practitioners speaks limited Spanish but occasionally requires assistance
communicating with patients. Most of this practitioner’s schedule is dedicated to serving LEP patients.

y Chinatown Pediatric Service (CPS) in Philadelphia is a fully bilingual clinic with staff who speak
English, Chinese, and Vietnamese. The clinic’s physician, Dr. Philip Siu, also serves as the director of
Thomas Jefferson University Hospital’s Chinese Health Information Center. Approximately 95 percent
of CPS’s patients speak Chinese (60 percent speak Mandarin; 40 percent speak Cantonese). Many
staff members are from Vietnam and speak Cantonese. Approximately 5 percent of patients are
ethnic Japanese, Cambodian, and French and can communicate adequately in English.

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11
13

Market culturally competent
services to the community to
ensure that communities that
need services receive the
information.

Determine and document the
linguistic needs of a patient or
legal guardian at first points of
contact, and periodically assess
them throughout the healthcare
experience.

National Quality Forum C-6

Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

Patient-Provider Communication—
Language Access
(continued)

Patient-Provider Communication—
Interpreter Services

y Saint Joseph Health System Community Health Programs, Santa Rosa, California, uses mobile
clinics to offer health and dental services. The Saint Joseph Mobile Health Clinic, in operation since
1990, offers health screenings and well-child exams, immunizations, treatment of minor medical
problems, health and nutritional education, other information, and referrals. The clinic serves
low-income children and adults who do not have regular primary care physicians and those who
have difficulty obtaining affordable healthcare. The clinic is in the field four days each week and
rotates among six high-need sites throughout Sonoma County. Most staff members are bilingual.
Approximately 97 percent of the patients are Spanish speaking.

y Los Angeles County Department of Health Services currently implements this practice. In its
implementation, it is further specified that signage be in at least the threshold languages for
MediCal Managed Care, and it will say: “You have the right to an interpreter at no cost to you.
Ask at the front desk.” In addition, a “Point to Your Language” card in at least the MediCal
threshold languages will be maintained at the points of contact for the patient.8

y Speaking Together, a National Language Services Network funded by the Robert Wood Johnson
Foundation, pilots new performance measures with hospitals and tests techniques for reducing
healthcare disparities. Hospitals should adopt these same practices by working toward core
measures for language services to track their performance.9

more

14 Maintain sufficient resources
for communicating with patients
in their primary written and
spoken languages through
qualified/competent interpreter
resources, such as competent
bilingual or multilingual staff,
staff interpreters, contracted
interpreters from outside
agencies, remote interpreting
services, credentialed volunteers,
and others, to ensure timely
and high-quality communication.

National Quality Forum C-7

Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

Patient-Provider Communication—
Health Literacy Strategies

Patient-Provider Communication—
Health Literacy Strategies

Patient-Provider Communication—
Cultural Awareness

Care Delivery and Supporting
Mechanisms—Clinical Encounter

y A study conducted by the Association of Clinicians for the Underserved in 2005 found that multiple
sites in Arizona, Michigan, Texas, and Washington use informal “teach back” methods to increase
and improve communication between patients and providers. The sites include Desert Senita
Community Health Center in Ajo, Arizona, Center for Family Health in Jackson, Michigan, Ferguson
Adult Health Center of the Cherry Street Health Services in Grand Rapids, Michigan, Community
Health Partnership, Inc., in Eau Claire, Wisconsin, and Parkland Health and Hospital System,
East Dallas Health Center.

y In 1997, Puget Sound Education Service District Head Start launched a Peer Health Education
Program in the Seattle area. The peer educators are Head Start parents who are trained to teach
other parents how to navigate the healthcare system and advocate for their families’ health.10

y The National Quality Forum evaluated three hospitals that met the criteria of having implemented,
at a minimum, the teach back component of (then) Safe Practice 2 as a routine practice for
informed consent or for related components of the surgical preparation process: 1) Sherman
Hospital, located in Elgin, Illinois; 2) Shriners Hospitals for Children-Los Angeles; and 3) the
University of Virginia Health System, in Charlottesville, Virginia.11

y The Joint Commission provides a self-assessment that hospitals can use.12

y UnitedHealthcare developed the Asian In-Language provider directory to promote patient-provider
racial, ethnic, and language concordance. Through better patient-provider matching, this initiative
facilitates effective communication of medical needs and enhanced medical outcomes by promoting
linguistic and cultural sensitivity. Anyone who has access to a computer can access this practice, and
those who speak Chinese, Korean, or Vietnamese will benefit from the ability to access the neces-
sary data in their own languages at any time. See www.uhcasian.com/English/guests/G_M_F.html.

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18
19
20
22

Use “teach back” as a patient
engagement tool to enhance
communication between the
healthcare provider and the
patient during clinical
encounters.

Communicate key information
about the proposed treatments
or procedures for which patients
are being asked to provide
informed consent.

Regularly assess attitudes,
practices, policies, and structures
of all staff as a necessary,
effective, and systematic way
to plan for and incorporate
cultural competency within an
organization.

If requested by the patient, pro-
vide resources such as provider
directories that indicate the
languages providers speak, so
that patients can have access to
this information.

National Quality Forum C-8

Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

Care Delivery and Supporting
Mechanisms—Physical Environment

Care Delivery and Supporting
Mechanisms—Coordination of Care

Care Delivery and Supporting
Mechanisms—Health Information
Technology

y The Lutheran Family Health Centers of Lutheran HealthCare provide a high-quality and convenient
healthcare safety net for neighborhoods throughout southwest Brooklyn. The clinics, such as the
Brooklyn Chinese Center and the Caribbean-American Family Health Center, provide services
matched to the needs of the communities they serve.13

y The Alaska Native Medical Center is a tribally owned and operated healthcare facility that provides
a full range of services to eligible Alaska Natives and American Indians who live in Alaska and has
tailored its clinics to reflect the populations they serve.14

y Hennepin County Medical System provides community liaisons to help patients who are receiving
services.15

y New York City’s Bellevue Hospital uses remote simultaneous medical interpreting (RSMI), a new
translation method that is improving patients’ experiences and outcomes. RSMI allows two parties to
speak into enhanced telephones while an off-site interpreter translates.

y Computer kiosks at Cook County Hospital clinics help patients with diabetes and low literacy skills
understand their susceptibility to complications.

y California’s Department of Managed Health Care provides approximately 5,000 farm workers and
their families with access to information about their medical conditions, medications, procedures,
and lab results. The information provided through this password-protected portal can be updated by
both patients and healthcare providers.

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25

26

27

Adapt the physical environment
where the healthcare is being
delivered to represent the
culture of the populations who
access their healthcare in that
environment.

Use culturally appropriate care
coordination services that take
into consideration the cultural
diversity of the populations
seeking healthcare.

Explore, evaluate, and
consider the use of multimedia
approaches and health informa-
tion technology to enable the
provision of healthcare services
that are patient and family
centered and culturally tailored
to the patient.

National Quality Forum C-9

Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

Workforce Diversity and Training—
Recruitment and Retention

Workforce Diversity and Training—
Recruitment and Retention

Community Engagement—
Community Outreach

y Mount Olive Pediatrics is a satellite office of Goldsboro Pediatrics in Mount Olive, North Carolina. It
employs bilingual midlevel practitioners who conduct examinations and clinical visits in Spanish and
also assist physicians and other office personnel during encounters with Spanish-speaking patients.
The office employs a bilingual certified pediatric nurse practitioner three days per week who coordi-
nates many of the language and cultural access activities. She also translates educational materials
and provides office staff with on-the-job training regarding Spanish terms, cultural beliefs, and
alternative medicine. A bilingual certified nurse’s assistant also sees Spanish-speaking patients.

y Goldsboro Pediatrics in North Carolina employs a part-time bilingual pediatrician at its other
offices throughout North Carolina. In addition, it employs a certified nurse assistant and two nurse
practitioners who have attended community college courses designed to improve conversational
Spanish skills.

y Barnes-Jewish Hospital in St. Louis, Missouri, has created a Center for Diversity and Cultural
Competence to promote diversity and cultural competence initiatives and programs throughout the
hospital and community and to oversee programs for its LEP patient population and through its
Refugee and Interpreter Services program.16

y University of Virginia Health Systems works closely with the local International Rescue Committee
(IRC) and health department to coordinate the healthcare of refugees in Charlottesville. Without the
IRC as a partner, the hospital would have to expend greater resources in caring for diverse refugee
populations by providing social workers, case managers, and interpreters for rare languages.

y The CEO at Sherman Hospital in Elgin, Illinois, appoints community members to serve on the
hospital’s governing board. As members retire from the board, the CEO strives to find new members
who represent the community’s demographic profile.

y As part of the New York public hospital system, Woodhull Medical and Mental Health Center is
required to have a community advisory board. The board meets monthly and serves as an advocate
for the community.

y Harborview Medical Center in Seattle, Washington, has a community advisory board specifically for
its Community House Calls program. The hospital uses this board to establish relationships with local
community groups, learn from community members, understand community-specific issues, and
provide a forum through which the hospital can receive feedback from its communities.

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28
29
31

Recruit and hire ethnically
diverse providers and staff at
all levels, including manage-
ment levels.

Actively promote the retention
of a culturally diverse work-
force through organizational
policies and programs.

Engage communities to ensure
that healthcare providers
(individual and organizational)
are aware of current and
changing patient populations
and cultural and communication
needs and provide opportunities
to share resources and
information.

National Quality Forum C-10

Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES
Community Engagement—
Community Outreach

y The three-year Diabetes Education and Treatment Initiative was launched in April 2005, in partner-
ship with La Clinica del Pueblo, one of the only free nonprofit health clinics serving uninsured
Latinos in Washington, DC. The three components of the program are implementation of the Chronic
Care Model, an evidenced-based approach that allows for the electronic tracking, monitoring, and
evaluation of client services; the provision of intensive education by culturally competent health
educators; and the use of a home visit diabetes counseling program that provides peer health
education or “promotores” to enhance self-management strategies.

y The Health Awareness for Immigrants Program in Sacramento, California, is a three-year
partnership with the Boat People SOS, a Vietnamese organization that promotes education for
early detection and treatment of cervical cancer for Vietnamese women. Using a multimethod
intervention, a mass media campaign targets local and national audiences, while bilingual health
advocates and trained volunteers provide ongoing case management and home visiting services to
link women with service providers.

y In a three-year partnership with the University of Maryland School of Medicine, CareFirst is
promoting cardiovascular health among African Americans through its Hair, Heart and Health (HHH)
program. Barbers, hair stylists and outreach workers are trained and certified as Blood Pressure
Measurement Specialists to provide health education and blood pressure screenings in barbershops
and hair salons in Baltimore City, Maryland.

y As part of a comprehensive strategy to address health disparities, CareFirst staff nurses and
physicians received cross-cultural training over a two-month period through a web-based program
called Quality Interactions developed by the Manhattan Cross Cultural Group in Marshfield Hills,
Massachusetts.

more

32 Collaborate with the community
to implement programs with
clinical and outreach components
to address culturally diverse
populations, health disparities,
and equity in the community.

National Quality Forum C-11

Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

Community Engagement—
Community Investments

Community Engagement—
Community-Based Participatory
Research

y In 2007, Massachusetts General Hospital (MGH) sought approval from the Massachusetts
Department of Public Health (DPH) to construct a new building on the downtown campus. Through
a “determination of need” process, DPH must set aside a portion of the project cost to improve the
health of the community. As a result, MGH will make an $18.6 million commitment to improving
the health of communities over the next five to seven years. This package will focus primarily on
MGH’s partner communities of Chelsea, Revere, and Charlestown.

y Montefiore Medical Center partners with national and community-based groups on health outreach
studies and programs that target specific needs—especially those of children, women, and seniors.
It has a development arm, Montefiore’s Mosholu Preservation Corporation, formed in 1981 to
promote the safety and vitality of the neighborhoods around its facilities, particularly in the
northwest Bronx, New York.

y Washington Hospital Center in Washington, DC, invests in the training, promotion, and evaluation
of its House Call Program aimed at delivering regular care in the patient’s home, improving the
quality of life for elderly residents.

y The Centers for Disease Control and Prevention funds three Urban Research Centers to conduct
community-based participatory research.17,18

y Supported by a grant from the W.K. Kellogg Foundation at the University of Michigan School of
Public Health, the Community Health Scholars Program (CHSP) is a postdoctoral fellowship program
designed to meet the growing needs of schools of public health and other health professions for
faculty who are culturally competent. The CHSP postdoctoral program enables scholars to develop
and enhance skills in working with communities and engaging in community-based participatory
research.19

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34
35

Healthcare professionals and
organizations should engage
communities in building their
assets as vehicles for improving
health outcomes.

Use the methodology of
community-based participatory
research when conducting
research in the community
as a collaborative approach to
research that equitably involves
all stakeholders in the research
process and fosters the unique
strengths that the community
brings to the process.

National Quality Forum C-12

Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

Data Collection, Public Accountability,
and Quality Improvement—
Collection of Patient Cultural
Competency-Related Information

Data Collection, Public Accountability,
and Quality Improvement—
Collection of Community Cultural
Competency-Related Information

Data Collection, Public Accountability,
and Quality Improvement—
Assessment of Patient Experiences
with Care

y Expecting Success and Speaking Together, both Robert Wood Johnson-funded programs, collect
race/ethnicity and primary written and spoken language data.

y The Agency for Healthcare Research and Quality has produced the National Healthcare Quality
Report and the National Healthcare Disparities Report, which measure trends in effectiveness of
care, patient safety, timeliness of care, patient-centeredness, and efficiency of care. They present,
in chart form, the latest available findings on the quality of and access to healthcare.21

y Expecting Success and Speaking Together, both Robert Wood Johnson funded-programs, collect
race/ethnicity and primary written and spoken language data.

y As part of a planning grant, WakeMed Health and Hospitals in Raleigh, North Carolina, conducted
a series of “secret shopper” visits to determine patient experiences with different areas of the
hospitals. The hospitals found that, in many cases, staff members were not able to communicate
with patients who did not speak English.

y Woodhull Medical and Mental Health Center sent a team to visit the Cambridge Alliance to observe
and learn from its cultural diversity and language programs. WakeMed Health and Hospitals visited
other North Carolina institutions, including a regional health department, to see how sites serving
similar populations provide language assistance services.

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36
38

43

Utilize the Health Research &
Educational Trust (HRET)
Disparities Toolkit20 to collect
patient race/ethnicity and
primary written and spoken
language data from patients in
a systematic, uniform manner.

Utilize indirect data collection
methodologies (e.g., geocoding,
surname analysis) to character-
ize the race, ethnicity, and
primary written and spoken
language of a community for
service planning and conducting
community-based targeted
interventions.

Assess and improve patient- and
family-centered communication
on an ongoing basis.

National Quality Forum C-13

Appendix C— Implementation Examples Cross-Walked to Practices
PRACTICE PRACTICE
DOMAIN—SUBDOMAIN NUMBER STATEMENT IMPLEMENTATION EXAMPLES

Data Collection, Public Accountability,
and Quality Improvement—
Documentation of Cross-Cultural
Complaints and Resolutions

y The Los Angeles County Department of Health Services maintains a log of cultural and language
complaints and complaint resolutions. This log is included in the facility’s required complaint report
issued quarterly.22

45 Ensure that conflict and griev-
ance resolution processes are
culturally sensitive and capable
of identifying, preventing,
and promptly and equitably
resolving cross-cultural conflicts
or complaints by patients or
between organizational staff.

NOTES
1 Los Angeles County Department of Health Services, Cultural and Linguistic Competency Standards; 2003, pp. 15-22.
2 The Disparities Solution Center, 17 Healthcare organizations selected for national leadership program to eliminate racial and ethnic disparities in healthcare; 2008. Press Release.
3 Schulze B, Krajik K, Trummer U, Migrant-Friendly Hospitals. Subproject C: Staff Training Toward Cultural Competence: Fact Sheet, Institute for the Sociology of Health and Medicine; 2004, pp.1-8. Available at www.mfh-eu.net/public/files/

experiences_results_tools/spc_training/SPC_factsheet . Last accessed February 2009.
4 California Health Care Safety Net Institute, Straight Talk: Model Hospital Policies and Procedures on Language Access. California Health Care Safety Net Institute; 2005. Available at www.safetynetinstitute.org/publications/documents/StraightTalkFinal .

Last accessed September 2008.
5 Medical Leadership Council of Cultural Proficiency, Language Access Database. Medical Leadership Council; 2009. Available at www.medicalleadership.org/resource_database.shtml
6 Rauber C, Kaiser makes $40M pitch: health plan gets a legume up on the competition, San Francisco Business Times; July 30 2004. Available at www.bizjournals.com/sanfrancisco/stories/2004/08/02/story2.html. Last accessed March 2009.
7 National Committee for Quality Assurance, Innovative Practices in Multicultural Health Care; 2006, pp. 14-15.
8 Los Angeles County Department of Health Services, Cultural and Linguistic Competency Standards; 2003, pp. 15-22.
9 The George Washington University Medical Center, Robert Wood Johnson Foundation, In Any Language: Improving the Quality and Availability of Language Services in Hospitals; 2008, pp. 3-15.
10 See http://eclkc.ohs.acf.hhs.gov/hslc.
11 National Quality Forum (NQF), Implementing a National Voluntary Consensus Standard for Informed Consent: A User’s Guide for Healthcare Professionals, Washington, DC: NQF; 2005.
12 Wilson-Stronks A, Lee KK, Cordero CL, et al., One Size Does Not Fit All: Meeting The Health Care Needs of Diverse Populations, Oakbrook Terrace, IL: The Joint Commission; 2008.
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16 See www.barnesjewish.org/groups/default.asp?NavID=3748. Last accessed March 2009.
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21 See www.ahrq.gov/qual/qrdr07.htm. Last accessed March 2009.
22 Los Angeles County Department of Health Services, Cultural and Linguistic Competency Standards; 2003, pp. 15-22.

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