Transcript No Slide Title

Levers for Change:
Strategies to Integrate
Cultural Competence Education
for Providers and Organizations
Robert C. Like, MD, MS
Professor and Director
Center for Healthy Families and Cultural Diversity
Department of Family Medicine
UMDNJ-Robert Wood Johnson Medical School
OBJECTIVES
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Identify the need for an ecological/systems approach to
cultural competency education and the elimination of
disparities in health and health care
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Discuss ten key levers of change for integrating cultural
competency into health professions training, clinical practice,
health care organizations, and service delivery systems
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Describe challenges related to developing, implementing,
and sustaining cultural competency educational programs
What is Cultural Competence?
“The ability of systems to provide care to patients with
diverse values, beliefs and behaviors including tailoring
delivery of care to meet patients’ social, cultural, and
linguistic needs. The ultimate goal is a health care system
and workforce that can deliver the highest quality of care
to every patient, regardless of race, ethnicity, cultural
background, [language proficiency, literacy, age, gender,
sexual orientation, disability, or socioeconomic status].”
Adapted and expanded from the Commonwealth Fund. New York, NY, 2002
Complex Adaptive Systems and
the Ecology of Health Care
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Health System
4
Practice
5
Local Community
1
Patient
3
Clinical
Encounter
2
Clinician
Crabtree BF et al. “Understanding practice from the ground up,”
The Journal of Family Practice 2001; 50(10):883.
Levers of Change
‘Levers’ are actions that can be taken
in order to change the behaviour of
an organisation and those individuals
within it.
Developing inclusive education systems: what are the levers for change?
Mel Ainscow, Professor of Education, University of Manchester, UK
http://portal.unesco.org/education/en/ev.php-URL_ID=29509&URL_DO=DO_TOPIC&URL_SECTION=201.html
Ten Key Levers of Change
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5.
Global Migration and Demographic Diversity
Political, Socioeconomic, and Market Forces
Funders and Purchasers
Research Studies and Policy Reports
Patient Safety, Risk Management, and
Liability Concerns
Ten Key Levers of Change, cont.
6. State and Federal Legislation
7. Standards, Accreditation Requirements,
and Guidelines
8. Leadership of Organizational Transformation
Activities relating to Patient- and Family-Centered
Care, Health Literacy, and Quality Improvement
9. Health Professions Workforce Diversification
10. Learning Communities, Collaboratives, and
Emerging Internet Technologies
State and Federal
Legislation
State Cultural Competency Legislation
New Jersey: Legislation Passed
California: Legislation Passed
Washington State: Legislation Passed
New Mexico: Legislation Passed
Maryland: Legislation Passed
New York: Legislation Pending
Ohio: Legislation Pending
Arizona: Legislation Pending
Kentucky: Legislation Pending
Georgia: Legislation Pending
Illinois: Legislation Died
Florida: Legislation Died
Colorado: Legislation Vetoed
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Dark Blue denotes legislation requiring (WA, CA, NJ, NM) or strongly recommending (MD)
cultural competence training, which was signed into law.
Purple denotes legislation which has been referred to committee and is currently under
consideration.
Royal Blue denotes legislation which died in committee or was vetoed.
http://www.thinkculturalhealth.com/cc_legislation.asp
State Legislation Passed
New Jersey: “Requires Physician Cultural Competency
Training as a Condition of Licensure”
Senate Bill 144, signed into law March 23, 2005
http://www.njleg.state.nj.us
California: Civil Code §51
“Continuing Medical Education on Cultural Competency”
AB 1195—Chapter 514, effective July 1, 2006
http://www.aroundthecapitol.com/Bills/AB_1195
Washington State: “Requiring Multicultural Education
for Health Professionals”
2006 Senate Bill 6194S, signed into law March 27, 2006
http://www.washingtonvotes.org/2006-SB-6194
New Mexico: “Health Program Cultural Competence Education”
48th Legislature, Regular Session, SB 600 signed March 30, 2007
http://legis.state.nm.us/lcs/_session.asp?chamber=S&type=++&number=600&year=07
Disparities-Related Legislative
and Policy Activities
Federal (pending)
S. 1576 Minority Health and Health Disparity Elimination Act of 2007
http://www.govtrack.us/congress/bill.xpd?bill=s110-1576
H.R. 3333 Minority Health Improvement and Health Disparity Elimination Act of 2007
http://www.opencongress.org/bill/110-h3333/show
H.R.3014 Health Equity and Accountability Act of 2007
http://www.opencongress.org/bill/110-h3014/show
State
Ladenheim K, Groman R. State Legislative Activities Related to Elimination of Health
Disparities. Journal of Health Politics, Policy and Law 2006; 31(1):153-184.
McDonough JE, Gibbs BK, et al. A State Policy Agenda to Eliminate Racial and
Ethnic Health Disparities. The Commonwealth Fund, June 2004.
http://www.cmwf.org/programs/minority/mcdonough_statepolicyagenda_746.pdf
Standards, Accreditation
Requirements, and
Guidelines
National Standards on Culturally and Linguistically
Appropriate Services (CLAS) in Health Care
Final Report
DHHS Office of Minority Health
Federal Register: December 22, 2000, Volume 65, Number 247, pages 80865-80879
www.omhrc.gov/CLAS
Emerging Accreditation
Requirements and Guidelines
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Joint Commission
National Committee on Quality Assurance
National Quality Forum
Liaison Committee on Medical Education
Accreditation Council for Graduate
Medical Education
Principles and Recommended Standards
for Cultural Competence Education
of Health Care Professionals - 2003
Cultures in the Clinic Project
Jean Gilbert, PhD, Chair and Editor
Julia Puebla Fortier, Co-Chair and Expert Consultant
Funded by the California Endowment
http://www.calendow.org/Collection_Publications.aspx?coll_id=26&ItemID=316
Nursing
Oral
Health
Allied
Health
Medicine
CULTURAL
COMPETENCE
EDUCATION
Public
Health
Mental
Health
Pharmacy
Social
Work
Tool for Assessing Cultural
Competency Training
(TACCT)
Association of American Medical Colleges
http://www.aamc.org/meded/tacct/start.htm
Accreditation Council for Graduate Medical
Education (ACGME) Outcomes Project:
General Competencies
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Medical Knowledge
Patient Care
Interpersonal and Communications Skills
Professionalism
Practice Based Learning and Improvement
Systems Based Practice
http://www.acgme.org/outcome/comp/compFull.asp#5
Professional Medical Organizations
The following are some of the specialty groups that have
published guidelines and/or policies relating to the care of
culturally diverse populations:
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Society of Teachers of Family Medicine
American Academy of Family Physicians
American Osteopathic Association
American Academy of Pediatrics
American College of Physicians
American Psychiatric Association
American College of Obstetrics and Gynecology
American College of Emergency Physicians
American Academy of Orthopaedic Surgeons
Second Language and Cultural
Competency Training for Continuing
Medical Education (CME) Credit
Funded by the California Endowment
http://www.calendow.org/Collection_Publications.aspx?coll_id=26&ItemID=316
Leadership of Organizational
Transformation Activities relating
to Patient- and Family-Centered
Care, Health Literacy, and
Quality Improvement
Beach MC, Saha S, Cooper LA. The role and relationship of cultural competence and patient-centeredness
in health care quality. The Commonwealth Fund, October 2006.
http://www.cmwf.org/usr_doc/Beach_rolerelationshipcultcomptpatient-cent_960.pdf
Health Literacy, Cultural Competence,
and Linguistic Competence
The Need for Integrative Approaches
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Patient Assessment Strategies
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Workforce Strategies
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Education and Training
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Other Main Strategies
Andrulis DP, Brach C: Integrating Literacy, Culture, and Language to Improve Health Care Quality for
Diverse Populations, American Journal of Health Behavior 2007:31 (Suppl 1):S122-S133.
Cultural Competency
Education Programs
• Live (group)
• Distance Learning (web-based)
• Blended
Improving the Quality of Care to
New Jersey’s Diverse Populations
6-hour Live CME Program
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Health Disparities, Cultural Competency, and
Implications for Quality Care
Caring for Diverse Populations: Understanding
Your Communities
Culturally Competent Patient-Centered Care
Caring for Patients with Limited English Proficiency
Addressing Cross-Cultural Health Literacy Challenges
in Clinical Practice
Becoming a Culturally Competent Medical Practice
Like, RC. Center for Healthy Families and Cultural Diversity,
of Family Medicine, UMDNJ-Robert Wood Johnson Medical School
Department
Cultural Competency E-Learning Programs
Federal Sector Examples
Office of Minority Health - A Physician’s Practical Guide to
Culturally Competent Care
http://cccm.thinkculturalhealth.org
Office of Minority Health - Culturally Competent Nursing Care:
A Cornerstone of Caring
https://ccnm.thinkculturalhealth.org
Health Resources and Services Administration - Unified Health
Communication: Unified Health Communication: Addressing
Health Literacy, Cultural Competency, and Limited English
Proficiency
http://www.hrsa.gov/culturalcompetence (to be posted)
Cultural Competency E-Learning Programs
Private Sector Examples
Manhattan Cross Cultural Group - Quality Interactions:
A Patient-Based Approach to Cross-Cultural Care
http://www.qualityinteractions.org
University Health System Consortium/UHC Learning Exchange™
Cultural Competence in Health Care
http://uhclearningexchange.uhc.edu/Presentations/pres-out67.html
Culture and Health Care: An E-Learning Course (based on
Cultural Sensitivity: A Guidebook for Physicians and
HealthCare) Doctors in Touch (DIT)
http://www.doctorsintouch.com/courses_for_CME_credit.htm
Medscape Health Diversity Resource Center
http://www.medscape.com/resource/healthdiverse
Murray-García JL, García JA. The Institutional Context of Multicultural Education:
What Is Your Institutional Curriculum? Academic Medicine 2008; 83(7):646-652.
Area F - What we planned was also taught and
learned
Area A - Formal curricular elements we wanted
to present, but couldn't/didn't
Area B - Undesirable behavior not directly
experienced by trainees
Area C - Excellent intent, but effects not
immediately felt by students
Area D - Curriculum not intended, but
nonetheless experienced by students
Area E - Good things learned but not taught
Area G - Things not taught, not intended, but
nonetheless experienced by students
Adapted from Coles CR, Grant JG. Curriculum evaluation in medical
and health-care education. Med Educ 1985; 19:405-422.
Health Professions
Workforce Diversification
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In the Nation's Compelling Interest: Ensuring Diversity
in the Health Care Workforce.
BD Smedley, AS Butler, LR Bristow, eds. Institute of Medicine.
Washington, DC, National Academy Press, 2004.
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Missing Persons: Minorities in the Health Professions:
A Report of the Sullivan Commission on Diversity in
the Healthcare Workforce. Sullivan Commission, 2004.
http://www.aacn.nche.edu/Media/pdf/SullivanReport.pdf
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The Case for Diversity in the Health Care Workforce.
JJ Cohen, BA Gabriel, C Terrell. Health Affairs 2002; 21(5):90-102.
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Student Body Racial and Ethnic Composition and
Diversity-Related Outcomes in US Medical Schools.
S Saha, G Guiton, PF Wimmers, et al. JAMA 2008; 300(10):1135-1145.
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Cultural Competence for the Health Workforce.
JE South-Paul, RC Like, in DE Holmes DE. From Education to Regulation:
Dynamic Challenges for the Health Workforce, Association of Academic Health
Centers, Washington, DC, 2008, pages 123-152.
http://www.aahcdc.org/policy/reports/From_Education_to_Regulation.pdf
Learning Communities,
Collaboratives, and
Emerging Internet
Technologies
NHLBI-funded National Consortium
for Multicultural Education
http://culturalmeded.stanford.edu
Selected National
Health Disparities Initiatives
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HRSA/IHI Health Disparities Collaboratives
www.healthdisparities.net
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AHRQ National Health Plan Collaborative
http://www.chcs.org/NationalHealthPlanCollaborative/index.html
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CMS Health Disparities/MedQIC Cultural Competency Initiatives
http://www.cms.hhs.gov/MedicaidSCHIPQualPrac/06_Healthdisparities.asp
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OMH Federal Collaboration on Health Disparities Research
http://www.omhrc.gov/templates/browse.aspx?lvl=1&lvlID=31
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IOM Health Disparities Roundtable
http://www.iom.edu/CMS/3793/44963.aspx
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IAF Disparity Reducing Advances Project
http://www.altfutures.com/draproject
Commission to End
Health Care Disparities
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American Medical Association
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National Medical Association
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National Hispanic Medical Association
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65+ other leading health professional
associations
www.ama-assn.org/go/healthdisparities
“A seven-part series for PBS broadcast and DVD release, will,
for the first time on television, sound the alarm about our
glaring socio-economic and racial disparities in health -- and
seek out root causes.”
http://www.unnaturalcauses.org
CDC Syndemics Prevention Network
http://www.cdc.gov/syndemics/index.htm
http://www.wikinomics.com/book
http://www.wired.com/techbiz/peo
ple/news/2008/09/crowdsourcing
_excerpt#
Ongoing Challenges
How can we …
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Identify the leadership and resources needed for
championing and supporting these initiatives?
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transform ourselves as individuals, organizations,
and health and social care delivery systems?
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generate interest, deal with resistance and inertia,
and support the desire to become more culturally
competent?
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address historical and contemporary “isms”
and “fears”?
Ongoing Challenges
How can we …
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partner and work more effectively with communities
and with key stakeholders/constituencies in the
public and private sectors?
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Calculate the return on investment and education
(ROI and ROE)?
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align the social, economic, and business cases
for cultural competence?
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support a more culturally competent and
participatory health policy environment?
Cultural Humility
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A lifelong commitment to self-evaluation and
self-critique
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Redressing power imbalances
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Developing mutually beneficial partnerships
with communities on behalf of individuals and
defined populations
Tervalon M, Murray-Garcia J: “Cultural humility versus cultural competence: a critical distinction in defining physician
training outcomes in multicultural education, “Journal of Health Care for the Poor and Underserved 1998; 9(2):117-124.
“Adding wings to caterpillars does not
create butterflies -- it creates awkward
and dysfunctional caterpillars. Butterflies
are created through transformation.”
Stephanie Pace Marshall