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Assuring Cultural Competence in Health Care:
Developing National Standards and an Outcomes-Focused Research Agenda

HHS Office of Minority Health
Agency for Healthcare Policy Research
Resources for Cross Cultural Health Care

Background | National CLAS Standards | Outcomes Research Agenda

Background

Cultural and linguistic competence suggests an ability by health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by patients to the health care encounter. For example, an elderly Bosnian woman being admitted with terminal cancer may present the following challenges for health care staff and organizations: she and her family do not read, speak or understand English; her Muslim faith requires modesty during physical examinations; and her family may have cultural reasons for not discussing end-of-life concerns or her impending death. A culturally and linguistically appropriate response could include interpreter staff; translated written materials; sensitive discussions about treatment consent and advance directive forms; clinical and support staff who know to ask about and negotiate cultural issues; appropriate food choices; and other measures. The provision of these kinds of services has the potential to improve patient outcomes and the efficiency and cost-effectiveness of health care delivery.

Unfortunately, many health care providers feel they don’t have clear guidance on how to prepare for or respond to these situations. As language about culturally and linguistically competent services proliferates in health policy discourse and practice, a common understanding of what this means is essential to assuring quality. Today, if a provider asserts they are culturally competent (which many increasingly do), it may be impossible for the consumer to know how that relates to services—if in fact it refers to specific services at all. Standards offer a guidepost for many different purposes and audiences. They set forth what should be done by service providers and how it should be done, and provide a basis for evaluation, comparison, and quality assurance by policymakers, consumers, and researchers.

To begin moving towards a national consensus on this issue, the U.S. Department of Health and Human Services Office of Minority Health (OMH) commissioned Resources for Cross Cultural Health Care and IQ Solutions, Inc. to review and compare existing cultural and linguistic competence standards and measures in a national context, propose draft national standard language where appropriate, assess the information or research needed to relate these guidelines to outcomes, and develop an agenda for future work in this area.

National CLAS Standards

The first phase of this project recommends national standards for culturally and linguistically appropriate services (CLAS) in health care. Originally based on an analytical review of key laws, regulations, contracts, and standards currently in use by federal and state agencies and other national organizations, these draft standards were developed with input from a national advisory committee of policymakers, health care providers, and researchers. Following publication in the Federal Register, the draft CLAS standards underwent a national process of public comment, and a final revision of the standards and accompanying commentary supported by the expertise of a second national project advisory committee. The final standards were published in the Federal Register on December 22, 2000 (Volume 65, Number 247, Page 80865-80879). Complete information about the project can be found at www.omhrc.gov/CLAS, and the final standards themselves are online at www.omhrc.gov/CLAS/indexfinal.htm.

The most significant potential impact of national standards for CLAS is that we can begin to replace the patchwork of different definitions, suggestions and requirements with one universally understood set of expectations. As the federal government has begun to include cultural and linguistic competence in an expanding number of important program rules and regulations, this uniformity of expectations is ideally started at the federal level.

In a separate project being undertaken by RCCHC with the George Washington University Center for Health Policy and Research for the Health Resources and Services Administration (HRSA) Center for Managed Care, the CLAS standards produced for OMH have been used in drafting model purchasing specifications on cultural competence for inclusion in state Medicaid managed care contracts. This model contract language contains detailed descriptions of cultural competence activities for both public and commercial managed care organizations, and can be found online at www.gwu.edu/~chsrp/pdf/ccs.pdf (this is an Adobe Acrobat file).

Outcomes Research Agenda on Cultural Competence

Funded by OMH and the Agency for Healthcare Research and Quality as a followup to the development of the CLAS standards, RCCHC is also facilitating the development of a health services research agenda on cultural competence in health care. As policymakers, accreditation bodies, and health care providers begin to support health services that are culturally and linguistically appropriate, questions inevitably arise about the intrinsic and relative value of different approaches, methods, and programs. These questions may relate to:

• access and outcomes (which interventions increase minority and LEP patients' access to healthcare services and/or improve their health outcomes?)
• quality and reduction in errors (which interventions increase the provision of appropriate care to and/or reduce the incidence of medical errors among minority and LEP patients?)
• cost (which interventions are cost effective, e.g., reduce diagnostic testing and emergency room use or increase preventive services lowering future health costs?)
• comparative analyses (which approaches to interventions work best under what circumstances?)
  

With input from a research advisory committee and the public, RCCHC will develop a research agenda intended to examine the research base underlying the field of CLAS in health care, identify issues associated with conducting research in this field, and suggest approaches for developing and implementing a CLAS research agenda. The final document is intended to be a guide for researchers and research funders interested in cultural competence.

For more information about the project, including how to offer comments on the draft research agenda and how to participate in an online discussion on cultural competence research issues, please visit the research agenda project pages. You may also contact Principal Investigator Julia Puebla Fortier at RCCHC@aol.com.

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