1 Physician Cultural Competency Independent Training Module for Simply Healthcare, Better Health and, Clear Health Alliance Providers
2 Purpose of Training This Cultural Competency training aims to ensure that: All providers associated with Simply Healthcare (SHP), Better Health (BET) and Clear Health Alliance (CHA) participate in basic training regarding cultural competency in order to meet the unique diverse needs of all members in the populations that we serve and to maximize the effectiveness of health care services provided to plan members, as described in provider contracts and the Cultural Competency Plan (CCP).
3 Training Objectives After this session physicians will be able to: Define culture, cultural awareness and cultural competence Understand the effect of culture on health care beliefs and practices for physicians and patients Identify personal barriers to providing culturally competent care Use culturally competent practices in the provision of health care services Understand how to assure that the needs of members with limited English proficiency are met Understand how to increase health literacy skills for member in their SHP, BET and CHA panels
4 What is Culture? Culture is the body of learned beliefs, traditions, principles, and guides for behavior that are commonly shared among members of a particular group. Culture serves as a roadmap for both perceiving and interacting with the world. Increasing Multicultural Understanding: A Comprehensive Model. Don Locke, SAGE Publications, 1992
5 What is Cultural Competence? Cultural competence is the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices and attitudes. It includes: Values and attitudes Communications styles Community/patient participation Physical environment, materials and resources Policies and procedures Population-based clinical practice Training and professional development
6 Culture and Healthcare Delivery In health care settings, cultural awareness, sensitivity, and competence behaviors are necessary because even such concepts as health, illness, suffering, and care mean different things to different people. Knowledge of cultural customs enables health care providers to provide better care and help avoid misunderstandings among staff, patients, and families. A Mather LifeWays Orange Paper by Dawn Lehman, PhD; Paula Fenza, MA; and Linda Hollinger- Smith, PhD, RN, FAAN. Available online at:
7 Culture and Healthcare Delivery Researchers posit that culturally competent health care has many benefits: more successful physician/patient education; increases in health careseeking behavior; more appropriate testing and screening; fewer diagnostic errors; avoidance of drug complications; greater adherence to medical advice; and expanded choices and access to high-quality clinicians. A Mather LifeWays Orange Paper by Dawn Lehman, PhD; Paula Fenza, MA; and Linda Hollinger- Smith, PhD, RN, FAAN. Available online at:
8 The Culturally Competent Physician A health care professional who has learned cultural competence engages in assistive, supportive, facilitative, or enabling acts that are tailored to fit with individual, group, or institutional cultural values, beliefs, and lifeways in order to provide quality health care. In other words, they demonstrate attitudes and behaviors that enable them to effectively work with individuals with diverse backgrounds. A Mather LifeWays Orange Paper by Dawn Lehman, PhD; Paula Fenza, MA; and Linda Hollinger- Smith, PhD, RN, FAAN. Available online at:
9 Barriers to Culturally Competent Care Beliefs Physician/Staff holds different beliefs about the nature of health and illness Physician/Staff believes in the omnipotence of Western medicine Physician/Staff believes in the omnipotence of technology Physician/Staff stereotypes culture groups Physician s/staff s misconceptions about the nature and quality of patients health care practices Physician s/staff s general interpretation of the cause of illness Physician/Staff assumes health professional knows best A Mather LifeWays Orange Paper by Dawn Lehman, PhD; Paula Fenza, MA; and Linda Hollinger- Smith, PhD, RN, FAAN. Available online at:
10 Barriers to Culturally Competent Care Attitudes Physician/Staff expects promptness Physician/Staff expects compliance Physician/Staff takes paternal approach Physician/Staff disrespects non-traditional healing practices Physician/Staff does not consider patients conflict regarding familiar belief systems and current practices Physician/Staff does not keep an open mind A Mather LifeWays Orange Paper by Dawn Lehman, PhD; Paula Fenza, MA; and Linda Hollinger- Smith, PhD, RN, FAAN. Available online at:
11 Barriers to Culturally Competent Care Behaviors Physician/Staff does not adjust approach to coincide with the needs of the patient Physician/Staff relies on technology/procedures to identify problem Physician/Staff limits time with patients Physician/Staff uses medical jargon Physician/Staff limits communications with family Physician/Staff tries to force use of Western medicine Physician/Staff does not agree on type and quality of care Physician/Staff miscommunicates A Mather LifeWays Orange Paper by Dawn Lehman, PhD; Paula Fenza, MA; and Linda Hollinger- Smith, PhD, RN, FAAN. Available online at:
12 Barriers to Culturally Competent Care Rituals Physician/Staff does not consider patients attitudes and beliefs regarding the physical examination Physician/Staff does not greet patients in a culturally appropriate way A Mather LifeWays Orange Paper by Dawn Lehman, PhD; Paula Fenza, MA; and Linda Hollinger- Smith, PhD, RN, FAAN. Available online at:
13 Examples of Consequences of Poor Cultural Competence A member does not comply with a treatment plan or take medications as prescribed because of a belief that Western medicine is too strong. A member s family makes important decisions about the member s care because in their culture major decisions are made by the family as a group while the physician deals only with the patient.
14 Goals for Cultural Competence in Healthcare Eliminate misunderstandings and errors in diagnosis and treatment planning that may arise from differences in language or culture Improve member adherence to treatments Eliminate health care disparities
15 Cultural Competence is a Continuum Gaining cultural competence is an ongoing PROCESS. It is developed as cultural knowledge increases. In order to achieve higher levels of competence, it is helpful to engage in self assessment. Self assessment provides S K I L L S direction for improvement. AT T I T U D E S K N O W L E D G E The Center for Public health Education
16 Cultural Competence is a Continuum Moving From Basic Knowledge to Clinical Practice K N O W L E D G E Understanding the meaning of culture and its importance to healthcare AT T I T U D E S Having respect for variations in cultural norms S K I L L S Eliciting patients explanatory models of illness Physicians must continue skill development to learn each culture Journal of the Nation Medical Association, Nov. 2008
17 The Patient s Explanatory Model of Illness Role of the Physician Ask questions to elicit the patient s understanding of their illness 2. Have strategies for identifying and bridging the different communication styles 3. Have skills for assessing decision-making preferences and the role of family 4. Utilize techniques for ascertaining the patient s perception of using biomedicine and his or her use of complementary and alternative medicine Journal of the Nation Medical Association, Nov. 2008
18 The Patient s Explanatory Model of Illness Role of the Physician cont Have tools for recognizing sexuality and gender issues 6. Have communication strategies for negotiating 7. Have an awareness of issues of mistrust and prejudices and of the impact of race and ethnicity on clinical decision-making Journal of the Nation Medical Association, Nov. 2008
19 Poor Health Literacy: A Hidden Barrier to Communicating with Members Illiteracy means lacking the ability to read and write. Health illiteracy means lacking the ability to: Obtain, process, understand basic health information and services Make appropriate healthcare decisions (act on information) Access/navigate the healthcare system
20 Health Literacy Research Researchers asked 395 primary care patients in 3 states, How would you take this medicine? 46% did not understand instructions on 1 labels 38% with adequate literacy missed at least 1 label Davis TC, et al. Annals Int Med 2006
21 Health Literacy Research Rates of Correct Understanding vs. Demonstration Take Two Tablets by Mouth Twice Daily Correct (%) Low Marginal Adequate Understanding Demonstration Davis TC, et al. Annals Int Med 2006
22 Strategies to Improve Patient Understanding and Health Literacy Focus on need-to-know & need-to-do Use Teach Back Demonstrate/draw simple pictures or diagrams Use clearly written education materials Do not talk down
23 Strategies to Improve Patient Understanding and Health Literacy Address what do patients need to know/do When they leave the exam room? When they check out of the physician s office? Before they go home? After they get home? What do they need to know about? Taking medicines Self-care Referrals and follow-ups
24 Strategies to Improve Patient Understanding and Health Literacy Use the teach back technique: Ensuring agreement and understanding about the care plan is essential to achieving adherence The physician can say: I want to make sure I explained it correctly. Can you tell me in your words how you understand the plan? Schillinger, D. Archives of Internal Med, 2003
25 Strategies to Improve Patient Understanding and Health Literacy Patients prefer receiving key messages from their physician with accompanying pamphlets over just getting pamphlets Focus should be need-to-know & need-to do Patients with low literacy tend to ask fewer questions; use teach back to develop and confirm understanding Encourage patients to bring medication to appointment to assure patient s understanding of how to use each medication prescribed; discuss what is there as well as what is missing but should be there IOM: Report on Health Literacy Berkman et al. AHRQ Report 2004
26 Strategies to Improve Patient Understanding and Health Literacy Use plain language Limit information (3-5 key points) Be specific and concrete, not general Demonstrate, draw simple pictures or models Repeat/summarize Teach back (confirm understanding) Be positive, hopeful, empowering
27 Addressing Language Differences Delivering good health care and changing health behaviors is hard enough without the added complication of language differences between a patient and health care provider. Speakers of languages other than English often do not get the health information they need. DeWalt DA, Callahan LF, Hawk VH, et al Health Literacy Universal Precautions Toolkit. AHRQ Publication No EF) April 2010.
28 Addressing Language Differences Addressing language differences is an important part of addressing health literacy universal precautions and is also a requirement by law. As part of the Civil Rights Act of 1964 and subsequent Federal and State laws and policies, a practice participating in Medicare or Medicaid is legally required to provide equal access to services for patients who do not speak or understand English well. DeWalt DA, Callahan LF, Hawk VH, et al Health Literacy Universal Precautions Toolkit. AHRQ Publication No EF) April 2010.
29 Addressing Language Differences Assess and document patients language preferences and language assistance needs ask all members: Would you like an interpreter? What language do you feel most comfortable speaking with the doctor or nurse? In what language would you feel most comfortable reading medical or health care instructions? DeWalt DA, Callahan LF, Hawk VH, et al Health Literacy Universal Precautions Toolkit. AHRQ Publication No EF) April 2010.
30 Addressing Language Differences Acceptable language assistance services: On-site trained interpreters Telephone medical interpreter services Bilingual clinicians and staff trained as interpreter; using untrained staff to interpret has been shown to lead to clinically significant medical errors Voice activated software that recognizes and translates phrases from one language to another, also known as a phraselator DeWalt DA, Callahan LF, Hawk VH, et al Health Literacy Universal Precautions Toolkit. AHRQ Publication No EF) April 2010.
31 Addressing Language Differences Planning for Interpretation Services: Tell patients that interpreters will be provided at no cost to them Patients may insist that staff communicate with bilingual family or friends and that request should be respected, but a trained interpreter should be in the room to assure that the information is accurately relayed Consider training your staff on how to work with interpreters DeWalt DA, Callahan LF, Hawk VH, et al Health Literacy Universal Precautions Toolkit. AHRQ Publication No EF) April 2010.
32 Addressing Language Differences Organizing language services: Office visits: For small populations of diverse patients, consider scheduling appointments at times when appropriate interpretation services are available Phone calls: Plan designated times that patients can call when interpreters are available Unscheduled communications: Have a plan for when a patient who you did not know needed language assistance comes in or calls (e.g., contract with medical telephone interpreters) DeWalt DA, Callahan LF, Hawk VH, et al Health Literacy Universal Precautions Toolkit. AHRQ Publication No EF) April 2010.
33 National Standards for Culturally and Linguistically Appropriate Services (CLAS) The US Department of Health and Human Services (HHS) Office of Minority Health (OMH) has issued national standards for Culturally and Linguistically Appropriate Services (CLAS). The standards are intended to be inclusive of all cultures and not limited to any particular population group or sets of groups; however, they are specially designed to address the needs of racial, ethnic, and linguistic population groups that experience unequal access to health services.
34 National Standards for Culturally and Linguistically Appropriate Services (CLAS) Principal Standard: 1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs
35 National Standards for Culturally and Linguistically Appropriate Services (CLAS) Governance, Leadership, and Workforce: 2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources 3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area 4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis
36 National Standards for Culturally and Linguistically Appropriate Services (CLAS) Communication and Language Assistance: 5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
37 National Standards for Culturally and Linguistically Appropriate Services (CLAS) Communication and Language Assistance continued: 7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.
38 National Standards for Culturally and Linguistically Appropriate Services (CLAS) Engagement, Continuous Improvement, and Accountability: 9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization s planning and operations. 10. Conduct ongoing assessments of the organization s CLASrelated activities and integrate CLAS-related measures into measurement and continuous quality improvement activities.
39 National Standards for Culturally and Linguistically Appropriate Services (CLAS) Engagement, Continuous Improvement, and Accountability continued: 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.
40 National Standards for Culturally and Linguistically Appropriate Services (CLAS) Engagement, Continuous Improvement, and Accountability continued: 13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. 15. Communicate the organization s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.
41 Self Assessment Please take a few minutes to check your cultural competency by answering the three questions that follow. Each question is asked on one slide and the correct answer is shown on the next slide.
42 Self Assessment: Question 1 1. Developing sensitivity and understanding of another ethnic group. This usually involves internal changes in terms of attitudes and values. This is called: a. Culture b. Cultural Awareness c. Cultural Competency
43 Self Assessment: Answer 1 1. Developing sensitivity and understanding of another ethnic group. This usually involves internal changes in terms of attitudes and values. This is called: a. Culture b. Cultural Awareness c. Cultural Competency
44 Self Assessment: Question 2 2. Your patient informs you that she is currently using an herbal remedy. Which is the most cultural sensitive response: a. State: Herbal remedies don t work. You need to take this prescription. b. Ask the patient about the herbal remedy, why they are taking it and discuss the benefits of a prescription medication instead. c. Give your patient a prescription and leave the room.
45 Self Assessment: Answer 2 2. Your patient informs you that she is currently using an herbal remedy. Which is the most cultural sensitive response: a. State: Herbal remedies don t work. You need to take this prescription. b. Ask the patient about the herbal remedy, why they are taking it and discuss the benefits of a prescription medication instead. c. Give your patient a prescription and leave the room.
46 Self Assessment: Question 3 3. Which is a benefit of cultural competency: a. Leads to improved diagnoses and treatment plans b. Allows clinicians to obtain more specific and complete information to make an appropriate diagnosis c. Reduces delays in seeking care and allows for improved use of health services d. All of the above
47 Self Assessment: Answer 3 3. Which is a benefit of cultural competency: a. Leads to improved diagnoses and treatment plans b. Allows clinicians to obtain more specific and complete information to make an appropriate diagnosis c. Reduces delays in seeking care and allows for improved use of health services d. All of the above
48 Cultural Competency Contacts and Resources Quality Management Department Lila Labarces, Director U.S. Department of Health and Human Services, Office of Minority Health. A Physician s Practical Guide to Culturally Competent Care Training for CME National CLAS Standards and Blueprint
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