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Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Background
Culture can be defined as the “personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions that are often specific to ethnic, racial, religious, geographic, or social groups.”[1]For both patients and providers, healthcare is defined through a cultural lens.[2]An individual’s cultural affiliations can affect where and how they seek care, how they describe symptoms, how they select treatment options, and whether they follow care recommendations.[2] Similarly, providers bring their own cultural orientations, including the culture of medicine.
Cultural competence in healthcare refers to the “ability of systems to provide care to patients with diverse values, beliefs and behaviors, including the tailoring of healthcare delivery to meet patients’ social, cultural and linguistic needs.”[3] Being a culturally competent health system requires behaviors, attitudes, and policies that support effective interactions in cross-cultural situations.[4]
Many models of cultural competence have been developed and these inform a collection of cultural competence interventions, such as provider training and practical tools. While the term cultural competence has predominantly referred to the culture and language of racial and ethnic minority groups, it is increasing being used to encompass other groups, such as people with disabilities and the LGBTQ community among other groups. These populations have been the primary subjects of studies of cultural competence interventions.[5] Cultural competence has also become linked with health literacy, an acknowledgement that mutual understanding between patients and providers calls for the integration of culturally and linguistically competent and health literate approaches.[2] This broadening of cultural competence is reflected in the updated National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care.
The cultural competence movement has grown with the rise of national attention to pervasive racial and ethnic disparities in healthcare.[6] Research has consistently demonstrated health and healthcare disparities between minority and majority populations.[7],[8],[9],[10] The demographic shifts that have created several minority-majority states and diversity in areas that were once homogenous have bolstered the case for cultural competence in healthcare.
Cultural Competence and Patient Safety
Disparities in healthcare extend to the patient safety arena. For example, a study that looked at hospitals across the country found that patients with limited English proficiency were more likely to be harmed than their English-proficient counterparts when they experienced adverse events, and that harm was more likely to be severe.[11] These findings extend to pediatric populations, such as the study that found that hospitalized Latino children are more likely to experience an adverse event than non-Latino white children.[12]
Patient safety events that can result from the failure to address culture, language, and health literacy include diagnostics errors, missed screenings, unexpected negative responses to medication, harmful treatment interactions from simultaneous use of traditional medicines, healthcare-associated infections, adverse birth outcomes, inappropriate care transitions, and inadequate patient adherence to provider recommendations and follow-up visits.[7] For example, lack of understanding that a hospitalized Asian woman would only communicate when a male family member was present, led to a delay in obtaining consent for a necessary surgery.[13] With growing diversity in patient populations across the country, the risk increases that differences between patients and providers will contribute to missed care opportunities and safety events.[7],[14]
In addition to affecting medical errors and harms directly, cultural competence can have a powerful effect on another driver of patient safety outcomes – patient engagement. Cultural and linguistic competence strategies, such as provision of language assistance and the use of cultural brokers, can promote effective communication with diverse patients that is critical to engage them as collaborative partners in their care. Other interventions, such as cultural competence training, can increase understanding of what the patient is experiencing and give providers skills to bridge cultural differences and foster increased trust.[15]
Approaches to Improving Cultural Competence
Provider cultural competence has the potential to decrease patient safety disparities.
Language Assistance
Language assistance, a strategy to overcome language barriers, can take the form of bilingual clinicians and staff and qualified foreign language and American Sign Language interpreters.[16] Successful language assistance relies on the adequacy of the supply of interpreter services, policies on using them, and training on how to access and work with interpreters. Otherwise providers might try to “get by” with the limited English skills of patients, their own inadequate foreign language skills, or unqualified interpreters, such as patients’ friends or family members or untrained staff.[17] Examples of documented patient safety events due to a lack of timely language assistance include performing an x-ray on the wrong part of the body, falls due to the patient not knowing to ask for assistance, and inability to treat emergency room patients due to failure to obtain medical history or medication list.[17]
Cultural Brokers
Using a cultural broker is one potential strategy to enhance cultural competence in healthcare. Cultural brokerage is the mediation between the traditional health beliefs and practices of a patient’s culture and the healthcare system.[18],[19] Interpreters, community health workers, and patient navigators can play the role of a cultural broker by providing context and by serving as a partner for both the patient and provider. While the role of the cultural broker can vary depending on patient and provider need, cultural brokers must be knowledgeable about the cultural group they serve and be able to successfully navigate the healthcare system. An individual acting as a cultural broker should be a trusted and respected member of the community but does not need to be healthcare professionals.[19] Incorporation of a cultural broker in the care team embraces the importance of cultural distinctions among patient groups. It also acknowledges that, particularly in very diverse communities, it is unrealistic for providers to have sufficient understanding of all of the different cultures present in the patient population they serve.
Cultural Competence Training
Cultural competence training programs aim to increase cultural awareness, knowledge, and skills, leading to behavior change.[20] Most reviews of cultural competence training conclude that training has positive impacts on provider outcomes, but as a standalone strategy training may insufficient to improve patient outcomes without concurrent systemic and organizational changes.[21]
AHRQ Project Spotlight – Re-Engineered Discharge (RED) Toolkit
Researchers at the Boston University Medical Center (BUMC) developed a set of 12 actions that hospitals should take during and after the patient stay to improve their discharge process. The most recent iteration of the RED Toolkit includes implementation guidance for delivering the RED to patients with diverse culture, language, race, ethnicity, literacy, sexual orientation, gender identity, etc. It also provides recommendations such as hiring bilingual, bicultural discharge educators, providing cultural and linguistic competence training, and ensuring availability of interpreter services. Further, the toolkit highlights how implementation of each RED component may need to be modified for diverse patient populations.[22] Links to publically available tools and resources that may assist with implementation are provided throughout the toolkit. Research has shown that the RED is effective at reducing readmissions and post-hospital emergency department visits.[23]
AHRQ Project Spotlight –TeamSTEPPS Limited English Proficiency Module
The AHRQ TeamSTEPPS Limited English Proficiency module is designed to provide hospitals with the tools to develop and implement a plan to train interpreter and clinical staff in teamwork skills, specifically within the context of working with patients with limited English. The module includes train-the-trainer resources and instructional guides that include short case studies and videos.[24] The success of TeamSTEPPS is well documented in the literature[25] and field testing of the LEP module concluded it was easy to implement and fostered staff learning.[26] In addition to implementing the TeamSTEPPS LEP module, the AHRQ guide Improving Patient Safety Systems for Limited-English-Proficient (LEP) Patients, recommends hospitals: 1) foster a supportive culture for safety of diverse patients, 2) adapt current systems to better identify medical errors among patients with LEP, 3) improve reporting of medical errors for LEP patients, 4) routinely monitor patient safety for LEP patients, and 5) address root causes to prevent medical errors among LEP patients.[27]
Cindy Brach, MPP
Senior Healthcare Researcher
Agency for Healthcare Research and Quality
Rockville, MD
Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health
IMPAQ International
Columbia, MD
Eleanor Fitall, MPH
Research Associate, IMPAQ Health
IMPAQ International
Washington, DC
References
[1] Cultural Respect. nih.gov. https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect. Updated February 15, 2017. Accessed December 5, 2019.
[2] Andruilis DP, Brach C. Integrating literacy, culture, and language to improve health care quality for diverse populations. Am J Health Behav.2007;31 Suppl 1:S122-33.
[3] Becoming a Culturally Competent Health Care Organization. aha.org. https://www.aha.org/ahahret-guides/2013-06-18-becoming-culturally-competent-health-care-organization. Accessed December 5, 2019.
[4] Brach C, Fraser I. Reducing disparities through culturally competent health care: An analysis of the business case. Qual Manag Health Care. 2002;10(4):15-28.
[5] Butler M, McCreedy E, Schwer N. et al. Improving Cultural competence to Reduce Health Disparities [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; 2016. https://www.ncbi.nlm.nih.gov/books/NBK361126/. Accessed December 5, 2019.
[6] Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc. 2008;100(11):1275-85.
[7] Brach C, Fraser I. Reducing disparities through culturally competent health care: An analysis of the business case. Qual Manag Health Care. 2002;10(4):15-28.
[8] Orgera K, Artiga S. Disparities in Health and Health Care: Five Key Questions and Answers. kff.org. https://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/. Published August 8, 2018. Accessed December 5, 2019.
[9] Piccardi C, Detollenaere J, Vanden bussche P, Willems S. Social disparities in patient safety in primary care: a systematic review. Int J Equity Health. 2018;17(1):114.
[10] Okoroh JS, Uribe EF, Weingart S. Racial and Ethnic Disparities in Patient Safety. J Patient Saf. 2017;13(3):153-161
[11] Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60-7.
[12] Stockwell DC, Landrigan CP, Toomey SL, et al. Racial, Ethnic, and Socioeconomic Disparities in Patient Safety Events for Hospitalized Children. Hosp Pediatr. 2019;9(1):1-5.
[13] Shepard S. Challenges of Cultural Diversity in Healthcare: Protect Your Patients and Yourself. thedoctors.com. https://www.thedoctors.com/articles/challenges-of-cultural-diversity-in-healthcare-protect-your-patients-and-yourself/. Published May 2019. Accessed December 19, 2019.
[14] Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc. 2008;100(11):1275-85.
[15] Beverley M. Connect Patient Engagement and Cultural competence to Drive Health Management. engagingpatients.org. http://www.engagingpatients.org/patient-centered-care-2/connect-patient-engagement-cultural-competence-drive-health-management/. Published August 14, 2014. Accessed December 5, 2019.
[16] Brach C, Fraser I, Paez K. Crossing the language chasm. Health Aff. 2005;24(2):424-34.
[17] Wasserman M, Renfrew MR, Green AR, et al. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual. 2014;36(3):5-16.
[18] Alexander GK, Uz SW, Hinton I, Williams I, Jones R. Culture brokerage strategies in diabetes education. Public Health Nurs. 2008;25(5):461-70.
[19] What is the Role of Cultural Brokers in Health Care Delivery? nccc.georgetown.edu. https://nccc.georgetown.edu/culturalbroker/2_role/index.html. Accessed December 5, 2019.
[20] Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57(Supplement 1):181-217.
[21] Truong M, Paradies Y, Priest N. Interventions to improve cultural competency in healthcare: A systematic review of reviews. BMC Health Services Research. 2014;14(1):99
[22] Re-Engineered Discharge (RED) Toolkit – Tool 4: How To Deliver the Re-Engineered Discharge to Diverse Populations. ahrq.gov. https://www.ahrq.gov/hai/red/toolkit/redtool4.html. Published March 2013. Accessed December 5, 2019.
[23] Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Ann Intern Med. 2009;150(3):178-87.
[24] Patients With Limited English Proficiency. ahrq.gov. https://www.ahrq.gov/teamstepps/lep/index.html. Accessed December 5, 2019.
[25] TeamSTEPPS Case Studies. ahrq.gov. https://www.ahrq.gov/teamstepps/case-studies/index.html. Accessed December 5, 2019.
[26] Wasserman M, Renfrew MR, Green AR, et al. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual. 2014;36(3):5-16.
[27] Improving Patient Safety systems for Patients With Limited English Proficiency. ahrq.gov. https://www.ahrq.gov/health-literacy/systems/hospital/lepguide/index.html. Accessed December 5, 2019.
Editor’s note: Cindy Brach, MPP is a Senior Healthcare Researcher at the Agency for Healthcare Research and Quality and is the Co-Chair of the HHS Health Literacy Workgroup. We spoke with her about the role of cultural competence in patient safety.
Ms. Brach has no conflict of interest to disclose.
Dr. Kendall Hall: Could you please provide an overview of your background, your current role at AHRQ, and how you became interested in the topic of cultural and linguistic competence?
Cindy Brach: I began working at AHRQ 23 years ago. Prior to that, I was the Associate Director of an organization called the Mental Health Policy Resource Center. Mental health was actually a trailblazer for defining cultural competence and I wrote a bit on the subject while in this role. The definition of cultural competence that is frequently cited in the field actually comes from work in children’s mental health. When I came to AHRQ, my boss had done some work on identifying non-financial barriers to care, one of which was the lack of cultural competence. We worked together on developing a conceptual model of how cultural competence might reduce disparities and created a business case for cultural competence. I have since served on the National Project Advisory Committee for both the original and 2013 revision of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. After which, I partnered with the Office of Minority Health to develop and publish a research agenda on cultural and linguistic competence.
KH: How does cultural competence relate to your current work on improving healthcare delivery?
CB: I’m the Co-Chair of the HHS Health Literacy Workgroup. From my perspective there is an inherent link between cultural competence, language barriers, and health literacy. I see them as each an overlapping circle in a Venn diagram. There are parts of the Venn diagram that do not overlap with the others, but there’s a core population of patients that has all three of these factors. The most obvious overlap is between linguistic competence and health literacy. If somebody is speaking a different language from you, you’re not going to understand. Health literacy is all about making information easy to understand, so when there are language barriers, you’re not promoting health literacy.
KH: How does patient safety fit into the Venn-diagram? Is it impacted by one discrete element or by all three?
CB: All three elements of the Venn diagram affect patient safety. They are actually cross cutting issues that affect all six of the quality domains identified in the IOM report, Crossing the Quality Chasm, including patient safety. Health literacy was actually one of two cross-cutting national priority issues identified in the IOM report, “Priority Areas for National Action: Transforming Health Care Quality.” Poor health literacy can have a big impact on patient safety. For example, when patients and clinicians have difficulty communicating, it can impact the clinician’s ability to make a diagnosis and/or the patient’s ability to understand that diagnosis. Similarly, language barriers have been associated with patient safety events. There is an article by Divi and colleagues that found that hospital patients with limited English proficiency experienced more harms and more severe harms than patients with proficient English.
I think another thing to consider is how these factors affect patient and family engagement. AHRQ has embraced patient and family engagement as an important component to achieve patient safety, and you cannot have engagement without addressing health literacy and cultural and linguistic competency.
KH: When you think about cultural, linguistic, and health literacy competencies and disparities as a patient safety issue, what is the link?
CB: According to the conceptual model mentioned previously, cultural competence can reduce disparities. However, I don’t want to oversell its ability to reduce disparities as there are many things that factor into disparities. There are some instances where you can see causal pathways and how you can disrupt that disparity process by implementing cultural linguistically competent interventions. However, even if there is not a disparity between English proficient and limited English proficient patients on any patient safety measure, it is still mandatory to provide equal access to communication for those patients. For example, you should still have bi-lingual clinicians, interpreter services, and things that will enable you to communicate to that population. This is based on an equal rights argument that says patients have the right to be able to communicate in healthcare and to be treated respectfully, regardless of any documented disparities.
KH: Do you think you have to understand a culture specifically to deliver culturally competent care?
CB: When it comes to cultural competence there is knowledge and there are skills. Cultural competence is very often defined as being able to work effectively across diverse populations. However, that tells you nothing about what you need to do to meet that goal. To me, being culturally competent is about having the skills needed to work cross-culturally. That means that regardless of my knowledge of a particular person’s culture, I have skills that enable me to put them at ease, to ask them about their health beliefs, to access resources, whether it be interpreter services or cultural brokers, that can support me in that relationship with the patient. However, what looks like good cultural competence varies among organizations. When you have a more homogenous population that you’re serving, you might hire on a staff interpreter, you might hire bi-lingual, bi-cultural clinicians and receptionists and billing clerks. That will put you in good stead to serve your target population, but that’s not going to be a great strategy if you’re serving a more diverse population. Then you need to be thinking about language banks, language lines, and where do you need community health workers or outreach groups that are responsible for different patient populations. It’s going to look different by necessity but can all result in cultural and linguistic competence.
KH: It sounds like one approach is to bring in people that are members of the community they’re serving.
CB: Yes, as I mentioned the definition of cultural competence doesn’t tell you what you need to do. When we were creating the conceptual model in 2000, we conducted a literature review and made a list of cultural competence strategies. This included approaches such as providing interpreter services, recruitment and retention of staff, training, coordinating with traditional healers, using community health workers, and culturally competent health promotion. Culturally competent health promotion is when you use culturally specific information about the community to tailor health promotion services and messages. For example, after discovering that a group of Cantonese-speakers worked several jobs and shopped on their sole day off, a health plan held health promotion classes in Cantonese in the area of the market on their specific day off.
KH: You mentioned something called a cultural broker. What is the purpose of that broker?
CB: A cultural broker is someone who understands two different cultures and mediates in cross-cultural interactions to help both parties understand each other. The broker role is usually combined with another staff function. For example, the role is often played by interpreters and community health workers in patient encounters. Cultural brokers can operate on an organizational level, such as when health organizations have a relationship with community-based organizations that give them cultural insights. Diverse members of patient and family advisory councils (PFACs) can also serve as cultural brokers. There are other ways for healthcare organizations to become more culturally sensitive. For example, California Medicaid plans were required to conduct a community needs assessment. Sometimes there are very influential people in the community who are gatekeepers to that community, for example a religious leader or an indigenous healer, who can play the broker role.
KH: You had mentioned the PFACs, is there an opportunity to make the PFAC more diverse and aligned with the communities they serve?
CB: Some places have, for example, a Spanish language PFAC. In a few places PFACs are required to be representative of the people who live in the healthcare organization’s service area. However, PFACs struggle to be economically and demographically diverse. I think that people are recognizing—to varying degrees– that having a diverse PFAC is important. Some organizations pay their PFAC members, in addition to providing child care and compensation for transportation.
KH: Could you please describe some of the projects you are currently involved in at AHRQ that help to address cultural competence?
CB: I will start with the TeamSTEPPS Limited English Proficiency module. This is a module that can be implemented as a stand-alone program or in combination with the complete TeamSTEPPS curriculum. It teaches how to include interpreters as part of the care team. Frequently the interpreter is not well integrated and only brought in on an as-needed basis with very minimal context about the care of the patient. What this module teaches is that the interpreter needs to be part of the team and that giving them patient safety responsibilities creates psychological safety for both the patient and the interpreter to speak up if they see a patient safety issue.
KH: Does the module go beyond health literacy and language barriers to include cultural considerations?
CB: The TeamSTEPPS module does not address cultural considerations. That is a much more cultural broker role and we do not discuss using interpreters, or others, as cultural brokers in the module. However the Re-Engineered Discharge (RED) Toolkit includes cultural considerations. The RED Toolkit, based on a modified discharge process tested in a randomized control trial, addresses how you should discharge diverse patients from different cultural and language backgrounds. The approach that the toolkit took was to create a separate tool called “How to deliver the re-engineered discharge to diverse populations” that focuses on nuances of delivering the RED to diverse patients. It specifically addresses some aspects of cultural and linguistic competence. Specific actions include hiring the right staff or bi-lingual, bicultural individuals and providing cultural linguistic competence training, translation and interpreter services, assessing communication needs, and taking into account different cultural considerations.
One aspect of the RED is making appointments for follow-up care before the patient is discharged. This may include a community health center or other primary care or specialty care services. It does not assume that these patients are low-income patients and instead approaches disparities from a cultural and linguistic perspective.
KH: You were previously interviewed [in 2013] for the AHRQ Innovation Exchange. Since that time, what has changed with regards to how we approach cultural and linguistic competence?
CB: Since then, the new National Standards for Culturally and Linguistically Appropriate Services (CLAS) have been released. The “Blueprint,” as it’s called, provides links to resources to support implementation. It also explicitly addresses health literacy; there is specific language throughout the Standards about how care has to be understandable to patients and families. With the CLAS Standards, the Office of Minority Health set out to answer the question: What do I do if I want to be a culturally competent organization? What does that mean? The Standards operationalize the definition.
KH: Are there resources hospitals can access to see how you design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness?
CB: There has been some work to develop assessment tools, but they haven’t really caught on for in-patient and out-patient settings. For example, there’s the Cultural Competency Implementation Measure that was developed by RAND and endorsed by the National Quality Forum. There’s also the cross-cultural communication component of the Communication Climate Assessment Toolkit (C-CAT). The language assistance piece is by far the most developed and has made the most head way in health care consciousness and implementation. For example, two measures of communication with people with limited English proficiency in AHRQ’s Consensus Organizational Health Literacy Quality Improvement Measures.
KH: Why do you think health literacy is more integrated into patient safety than cultural competence?
CB: I think that has to do with health literacy more generally. I think that health literacy has appealed more because it’s your grandmother, it’s you. Everyone can come up with a personal example of when they’ve been frustrated after being given an incomprehensible set of instructions, or after being sent to 20 different providers. Unfortunately, I do not think that cultural competency has made the same inroads, because it’s seen as benefiting only a segment of patients – minority patients. Patient safety is a big numbers game. If you’re looking at rates of infection in a hospital over a period of time, moving the needle on those rates for a group that only represents a small portion of your population – it is not going to be that much help to you when trying to meet your overall patient safety goal. So there is less investment in trying to fix that problem.
KH: What are the next steps in this field? Where are we going and where should we be going?
CB: I think there has been a fair bit of stagnation in recent years in the cultural and linguistic competence area. I think that in order to make headway now, people have to walk the walk. For example, in the case of accreditation auditors. When they have standards that relate to equity, communication, or any other areas in which disparities occur, they have to really enforce them or people are not going to pay attention. There are organizations that are trying to improve the cultural competence because they know it is the right thing to do and will ultimately improve their outcomes and serve their patients better. However, to really move the needle there has to be some alignment of incentives. For example, payments could be linked to reducing disparities, which could encourage investment in cultural and linguistic competence. Using quality measures is another approach. For example, there is a hospital that I know of that decided they were going to measure whether there were at least 2 interpreter encounters in a 24 hour time period. Now, is that the right number? Is that going to be the right time period? Who knows! But it sends a message throughout the organization that there is an expectation that you will use the interpreters and that there is accountability. Some states have mandated cultural competence training as part of medical licensing requirements. But I don’t think we have evidence as to whether that’s produced a more culturally competent workforce, or just given rise to a training industry that may or may not be providing effective training.
KH: Is there anything that we didn’t cover today that you would like to discuss?
CB: Addressing language barriers is usually the first place that organizations turn to when they start addressing cultural competence, and that’s great. Let’s do that. But it is important to recognize that cultural competence is a separate competence from addressing language barriers and that it may require a different kind of intervention. My impression is that patient safety pays a lot more attention to errors of commission than omission, and a lot of the cultural and linguistic competence errors are errors of omission.
