The CEO Refresher - Why Cultural Competence Matters in Healthcare Organizations

We have all heard stories, listen to news, or read studies that indicate the United States is metaphorically turning into a big melting pot. I propose this metaphor is an inaccurate description of our country now and most certainly in the future. I believe William Sonnenschein's description of who we are seems more relevant. We are much more like a garden salad. A garden salad is made up of many vegetables of different tastes and textures. (1) Said another way, we are many cultures with many differences. Hopefully, you can embrace this latter view as more fitting as I discuss reasons why cultural competence matters to healthcare organizations in the 21st century.

This article explores why cultural competence matters in health care. The article serves as a wake-up for boards, CEOs, and senior healthcare executives as they strategically align their organizations with 21st century challenges. Finally, the article highlights some useful resources for health care CEOs and senior leaders desiring to learn more on the topic. But first, some background information.

Background

U. S. census reports indicate America's population is growing increasingly diverse. In 1900, only one in eight Americans was of a race other than white - today, that ratio is one in four. By 2050, the Hispanic and Asian populations will both triple, the black population will almost double, and the white population will barely hold its own (Salisbury and Byrd, 2006, p. 90)(2) . This diversity creates a rich cultural texture in America, but also brings challenges to the health care community with implications for every aspect of health care - the workforce, leadership, and most importantly, the communities served. The authors explain as the United States become more ethnically and racially diverse, there is a need for healthcare organizations that can reflect and respond to an increasingly heterogeneous community. Knowing how to serve people with different values, health beliefs and alternative perspectives about health and wellness is both a business and ethical imperative. A brief definition of cultural competence offers a practical starting point.

What is Cultural Competence?

The Department of Human & Health Services, Administration on Aging (2001) defines cultural competence as a set of cultural behaviors and attitudes integrated into the practice methods of a system, agency, or its professionals that enables them to work effectively in cross cultural situations. (3) Cultural competency is achieved by translating and integrating knowledge about individuals and groups of people into specific practices and policies applied in appropriate cultural settings. When professionals are culturally competent, they establish positive helping relationships, engage the client, and improve the quality of services they provide which leads us to why cultural competence matters in health care.

Why Cultural Competence Matters

The following landmark reports and health care delivery related illustrations provide what I believe to be ample argument for developing cultural competence in health care. Consider the following:

In 2002, the Institute of Medicine (IOM) published a groundbreaking report, titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, which illuminated one of the most critical health care challenges facing the United States. The IOM's findings that racial and ethnic minorities receive lower-quality health care than white people - even when insurance status, income, age, and severity of conditions are comparable - for the first time gave evidence-based credence to the assertion that the U.S. health care system is not color blind. The report offered comprehensive evidence to an uncomfortable reality-some people in the United States were more likely to die from cancer, heart disease, and diabetes simply because of their race or ethnicity, not just because they lack access to health care. (4) (p. 3)

In a 2001 national survey conducted by The Commonwealth Fund, a private foundation that aims to promote a high performing health care system, 39% of Latinos, 27% of Asian Americans, 23% of African Americans, and 16% of whites reported communication problems: Their doctor did not listen to everything they said, they did not fully understand their doctor, or they had questions during the visit but did not ask them. (5) (p. vii)

A 2006 National Healthcare Disparities Report by the Agency for Healthcare Research found disparities related to race, ethnicity, and socioeconomic status pervades the American health care system. The report notes although varying in magnitude by condition and population, disparities were observed in almost all aspects of health care. (p. 2)

American health care puts a great deal of emphasis on patient autonomy and patients' "right to know." This attitude is not shared by all cultures, however, and is contrary to the dominant beliefs of many societies. The custom in many cultures, including Mexican, Filipino, Chinese, and Iranian, is for a patient's family to be the first to hear about a poor prognosis, after which the family decides whether and how much to tell the patient. Members of such cultural groups may believe that it would be insensitive for a patient to be told bad news and that this would only cause the patient great stress and even hasten death by destroying hope. (6)

When the doctor entered the exam room to meet with his Iranian patient, he found Seyyed huddled on the floor, mumbling. At first he thought Seyyed had fainted, fallen off the table, and perhaps struck his head. But when he tried to help him up, the patient became agitated and resisted his help. Seyyed spoke no English, and the doctor had no idea what the problem was. He later learned that Seyyed had been praying. The Muslim would have preferred to pray on a prayer rug in a place where he wouldn't be interrupted, but it was growing late for the fourth of his five mandatory daily prayers. If the doctor had had an understanding of Islamic customs, he would have realized that his patient was praying and would have given Seyyed some privacy (Galanti, 2000).

Lack of eye contact in American culture may indicate many things, most of which are negative. A physician may interpret a patient's refusal to make eye contact as a lack of interest, embarrassment, or even depression. However, a Chinese patient may be showing the physician respect. If the patient is female and from a Muslim country, and the physician is male, she may be trying to avoid sexual impropriety. A Navaho patient may be trying to avoid soul loss or theft. Knowing the meaning of eye contact, or lack thereof, may help avoid misinterpreting a patient's behavior. (7)

From the reports and illustrations and many others not mentioned here, the rationale and leadership mandate is apparent: cultural competence in health care matters. It is an ethical, patient safety, and quality of care concern. Cultural competence is a health care business imperative.

Helpful Resources

The following resources provide CEOs and senior leaders a vigorous starting point for learning more on the topic of cultural competence in health care.

The Institute of Medicine (IOM) is one of the United States National Academies, and is a not-for-profit, non-governmental American organization chartered in 1970 as a part of the National Academy of Sciences; its purpose is to provide national advice on issues relating to biomedical science, medicine, and health. It works outside the framework of the government to provide independent guidance and analysis. An electronic version of Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare and other reports are available at http://www.iom.edu/.

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. The Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. The report, Racial and Ethnic Disparities in Access to and Quality of Health Care and other studies and reports are available at http://www.rwjf.org/.

The Commonwealth Fund is a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. Studies, articles, and reports are available at http://www.commonwealthfund.org/.

The Office of Minority Health (OMH) was established in 1986 by the U.S. Department of Health and Human Services. It advises the Secretary and the Office of Public Health and Science on public health program activities affecting American Indians and Alaska Natives, Asian Americans, Blacks/African Americans, Hispanics/Latinos, Native Hawaiians, and other Pacific Islanders. OMH's mission is to improve and protect the health of racial and ethnic minority populations through the development of health policies and programs that will eliminate health disparities. The "National Standards for Culturally and Linguistically Appropriate Services in Health Care: Executive Summary" and other information are available at http://www.omhrc.gov/.

The Agency for Healthcare Research and Quality (AHRQ) is part of the United States Department of Health and Human Services which supports research designed to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, and broaden access to effective services. It sponsors, conducts, and disseminates research to help people make more informed decisions and improve the quality of health care services. The 2006 National Healthcare Disparities Report and other reports are available at http://www.ahrq.gov/.

The Joint Commission offers two guides, "The Joint Commission 2007 Requirements Related to the Provisions of Culturally and Linguistically Appropriate Health Care" and "Office of Minority Health National Culturally and Linguistically Appropriate Services (CLAS) Standards Crosswalked to Joint Commission 2007 Standards for Hospitals, Ambulatory, Behavioral Health, Long Term Care, and Home Care" available at http://www.jointcommission.org/.

Conclusions

The imperative to become culturally competent is unconditional for healthcare organizations. Meeting the health care challenges brought on by demographic changes taking place in the 21st century precludes CEOs and senior healthcare executives from being passive bystanders in their communities but rather insists that they ethically employ all resources at their command to preserve and improve the communities served. Swedish (2007) concludes a culturally competent healthcare organization is better able to effectively and respectfully serve patients from a rich variety of cultures, with differing ideas, experiences and perspectives. (8) Leadership must be the catalyst for developing culturally competent healthcare organizations. I hope this article prompts you to learn more about cultural competence. If so, you have taken the first essential step.

References

Sonnenschein, W. (1997) The Diversity Toolkit. Lincolnwood: Contemporary Books.
Salisbury, J. & Byrd, S. (2006). Why Diversity Matters in Health Care. CSA Bulletin, 55, 1, 90-93. Retrieved February 24, 2008 from http://www.csahq.org/pdf/bulletin/issue_12/Diversity.pdf
U. S. Department of Health & Human Services. (2001). Achieving Cultural Competence: A Guidebook for Providers of Services to Older Americans and Their Families, p. 9. Administration on Aging. Retrieved December 16, 2007 from http://www.aoa.gov/prof/adddiv/cultural/cc-guidebook.pdf
Institute of Medicine. (2005). Addressing Racial and Ethnic Health Care Disparities: Where Do We Go From Here? Retrieved February 5, 2008 from the Institute of Medicine website: http://www.iom.edu/Object.File/Master/33/249/BROCHURE_disparities.pdf
Collins, K. S., Hughes, D. L., Doty, M. M., Ives, B. L., Edwards, J. N., & Tenney, K. (2002). Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans, Findings from the Commonwealth Fund, 2001 Health Care Quality Survey. Retrieved February 11, 2008 from the Commonwealth Fund website: http://www.commonwealthfund.org/usr_doc/collins_diversecommun_523.pdf?section=4039
Galanti, G. (2000). An Introduction to Cultural Differences. Culture and Medicine, 172, 335-336. This article is available at http://www.ggalanti.com
Chin, P., Lipson J.G., Dibble S.L., & Minarik, P.A. (1996) Culture and Nursing Care: A Pocket Guide. San Francisco: University of California-San Francisco Nursing Press; 1996:74-81.
Swedish, J. (2007). Guest Commentary: Healthcare's Cultural Imperative in a Diverse Society. Modern Healthcare Online. Retrieved online from http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070822/FREE/308220023