Implementing Cultural and Linguistic Competence in ...

Implementing Cultural and Linguistic Competence in the Curriculum

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Implementing Cultural and Linguistic Competence in Healthcare Management Curriculum Marilyn V. Whitman, PhD & Jullet A. Davis, PhD

Abstract As our nation’s population continues to diversify, the need to provide culturally and linguistically appropriate services will intensify. In the healthcare industry, specifically, it is imperative that the services provided are congruent with patients’ beliefs and practices in order to avoid fatal and costly errors. Much attention has been given to the role of clinicians in providing appropriate services to racially and ethnically diverse groups to eliminate disparities and lessen barriers to access. The need for cultural and linguistic competence, however, extends beyond clinicians. This paper discusses the need to add cultural and linguistic competencies to the healthcare management curriculum and presents a set of core competencies for healthcare management majors. A core competency model is presented along with discussion suggestions and student activities designed to make the learning process intellectually stimulating and improve student receptivity.

Introduction The recent surge in the number of foreign-born individuals has resulted in increased awareness of the need for professionals in all parts of society to provide services that are culturally and linguistically (CAL) appropriate. This is especially true in the healthcare industry where it is imperative that services are congruent with patients’ beliefs and practices. The increase in Please address correspondence to: Marilyn V. Whitman, PhD The University of Alabama Management and Marketing Department, Box 870225, Tuscaloosa, AL 35487, Tel: (205) 3488934, Fax: (205) 348-6695, [email protected]

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The Journal of Health Administration Education

Spring 2008

medical errors and legislative focus on cultural and linguistic competence has captured the industry’s attention. Providing services that are culturally and linguistically competent is vital to ensuring that the provision of care is equitable and cost-effective. There is, however, little mention in the literature of the importance of preparing future healthcare managers to lead these efforts. The U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) (2005) states that “as organizations evolve along a development continuum that moves from ignoring cultural and linguistic differences in patients to one that carefully considers the effect of cultural variation on patient care, the changes required for such a complex process must be managed carefully.” It is crucial that healthcare leaders understand the role that cultural and linguistic competence plays in lessening barriers to access, eliminating disparities, and ensuring equitable care to all patients. Effectively managing the diversifying workforce and patient population results in benefits such as greater market share, improved customer satisfaction, improved quality of care, increased labor pool despite a scarce labor market, labor cost savings, reduction in turnover, and more effective teams (Dreachslin 1996). This paper seeks to develop the case for the implementation of cultural and linguistic competence in a healthcare management curriculum. The authors review the benefits and challenges associated with the provision of culturally and linguistically appropriate services and define the role of leadership in managing a diversifying patient and workforce population. A conceptual model illustrating the provision of culturally and linguistically appropriate care in a healthcare organization is introduced as well as a set of core competencies for healthcare management majors. Examples of classroom discussions and activities designed to make the learning process intellectually stimulating and improve student receptivity follows.

Background and Significance In 2005, the Census Bureau estimated that nearly 36 million foreign-born individuals currently resided in the U.S. That same year, the Census Bureau estimated that 21 million people were linguistically isolated or limited English proficient (LEP), up from nearly 12 million in 2000 (U.S. Census Bureau 2003). In addition, nearly 52 million people, or 19.4 percent of the total population, spoke a language other than English in their homes (U.S. Census Bureau 2005). Future projections show that by the year 2050, minorities will account for nearly 50 percent of the nation’s population (Suh 2004).


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Today, cultural differences and language barriers are creating significant challenges in the delivery of healthcare. Approximately 6.4% of physicians and 10.7% of registered nurses identify themselves as a racial or ethnic minority; many of these providers are located in inner-city and urban centers leaving the suburban and rural areas without sufficient coverage (AAMC 2006; HRSA 2006). A recent American Medical Association (2006) study of hospital language services found that 63% of hospitals across the nation reported encountering patients with language barriers either daily or weekly. Furthermore, approximately 68% of hospitals reported having a medical interpreter on staff. The study, however, noted that similar to provider demographics, many of these hospitals are located in larger urban areas where LEP patients have historically congregated. In a study examining cultural and linguistic competence in Alabama general hospitals, Whitman and Davis (2008) report that nearly 51 percent of hospital Chief Executive Officers stated they did not have a trained interpreter on staff. Of these respondents, 96 percent indicated they did not have a trained interpreter on staff due to the difficulty in finding medical interpreters and 75 percent indicated it is too expensive to hire a trained interpreter. For areas that were previously impervious to diverse patient populations, providing and financing language access services, including around-the-clock medical interpreters and translated documents, may be cost-prohibitive. Conversely, facilities that have a diverse patient population representing various different cultural groups and languages may find it especially difficult to provide interpreters and translated documents for all the languages present. Along with the challenges associated with the lack of an interpreter, there are also issues surrounding the use of appropriate interpreters. Herndon and Joyce (2004) argue that communicating with LEP patients “requires more than simply ‘finding someone who speaks their language.’” Without proper training, providers may further alienate the patient by speaking directly to the interpreter, using jargon or terms that are difficult to translate, and not allowing the extra time necessary for interpreting and discussion. Given the growth in LEP patients that is occurring in all regions of the U.S., it is vital that healthcare managers in all settings in all locations become better versed in the cultural and language needs of this subset of patients. The lack of culturally competent providers and the limited availability or improper use of medical interpreters is resulting in little to no use of primary care services, poor patient-provider relationships, incorrect diagnosis, lack of informed consent, a higher number of tests performed, decreased patient compliance with physician directives and follow-up care, increased costs,

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lower patient satisfaction, and even malpractice suits (Baker, Hayes, and Fortier 1998; Hampers, Cha, Gutlass, Krug, and Bennis 1999; Carrasquillo, Orav, Brennan, and Burstin 1999; Ferguson and Candib 2002; Herndon and Joyce 2004; Ku and Flores 2005). Moreover, in 2002 the Institute of Medicine (IOM) report titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare concluded that despite having the same health insurance coverage, racial and ethnic minorities do not receive the same quality of healthcare as non-Hispanic Whites. The IOM states that in addition to factors such as differences among racial and ethnic groups’ variations in help-seeking behaviors, treatment preferences, and response to treatment, the “bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care.” As the patient population continues to diversify, the need to manage diversity by creating an organizational culture that values differences will prove crucial in enhancing both customer and employee satisfaction and increasing organizational performance through improved patient outcomes (Medrano, Setzer, Enders, Costello, and Benavente 2005).

The Role of Culture in Healthcare The U.S. Department of Health and Human Services Office of Minority Health (OMH) notes the importance of the role that culture plays in how a patient defines illness and health (OMH 2001a). A patient’s cultural beliefs and practices have a powerful influence on his or her understanding of illness, perceptions of healthcare providers, and treatment preferences. Cultural awareness and knowledge, therefore, are necessary for healthcare providers to offer greater accessibility, obtain proper informed consent, improve cooperation in treatment, and ensure confidentiality. The term “cultural competence” was first used by Cross, Bazron, Dennis, and Isaacs (1989) in their study of how to improve service delivery to minority children who were emotionally disturbed. The authors defined cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.” The authors argued that to develop a culturally competent system, organizations must carefully plan for it. Strategic planning must include assessing the organization’s internal and external environment, generating a support base to help facilitate action and change, allocating the appropriate resources needed to aid in the implementation effort, maintaining leadership involvement, and creating a mission statement to establish direction.


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Since the coinage of the term cultural competence, a number of authors have offered their own definitions. Some authors distinguish cultural competence as a complex integration of cultural awareness, knowledge, attitudes, skills, and encounters (HRSA n.d.; NCCC 2004; Denboba 1993). Others describe it as a distinct concept that integrates cultural sensitivity and knowledge (Kim-Godwin, Clarke, and Barton 2001). Although slight variations appear in the definition of cultural competence, there is unwavering agreement among researchers in the fields of medicine, nursing, and social work on its necessity in today’s changing world (Leininger 1978, 1995; Dobson 1991; Andresen 2001; Campinha-Bacote 2002; Purnell and Paulanka 2003; Andrews and Boyle 2003; Giger and Davidhizar 2002, 2004; Spector 2004; Betancourt, Green, Carrillo, and Park 2005). Purnell and Paulanka (2003) argue that in today’s global society, cultural competence should not be regarded as a luxury, rather a necessity. Spector (2004) states that individuals learn how to be healthy, as well as how to be ill, from their cultural and ethnic conditioning. Furthermore, Betancourt, Green, Carrillo, and Park (2005) state that “cultural competence aims to change a ‘one size fits all’ healthcare system to one that is more responsive to the needs of an increasingly diverse patient population.” Cultural competence, therefore, requires healthcare professionals to be aware of and respect an individual’s cultural uniqueness in order to better meet his or her needs and expectations and provide the most effective care. Dreachslin (2007a) adds that “health systems that are aware of these differences in culture and that have systems in place for responding to those differences are on the right track to increasing patient satisfaction, improving processes and outcomes of care, and minimizing conflict between institutional practices and diverse patient cultures.”

The Role of Communication in Healthcare Linguistic competence, although closely linked to cultural competence, requires a different set of knowledge and skills (HRSA 2005). The National Center for Cultural Competence (NCCC) (2004) defines linguistic competence as “the capacity of an organization and its personnel to communicate effectively and convey information in a manner that is easily understood by diverse audiences including persons of limited English proficiency, those who have low literary skills or are not literate, and individuals with disabilities.” The Agency for Healthcare Research and Quality (AHRQ) adds that linguistic competence consists of providing oral and written language access services that include qualified interpreters and translated documents in the patient’s preferred language.

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Healthcare providers that receive federal monies are mandated by law to provide LEP patients with reasonable access, both written and oral, to services in their proficient language. Accrediting agencies such as the Joint Commission on the Accreditation of Healthcare Organizations and the National Committee for Quality Assurance have also adopted standards requiring healthcare organizations to make language access services available. Additional rationales for linguistic competence include improving access to healthcare services, increasing market share, reducing costs of diagnosis and treatment, and decreasing the likelihood of malpractice suits (Baker and Parker 1996; Hampers, Cha, Gutglass, Krug, and Binns 1999; Carrasquillo, Orav, Brennan, and Burstin 1999; Ferguson and Candib 2002).

Cultural Competence Curriculum Standards in Healthcare The increasing awareness of the need for healthcare providers to be CAL competent and provide care that is culturally appropriate has resulted in the adoption of curriculum standards by medical and nursing schools. In 2005, the Association of American Medical Colleges (AAMC) developed curriculum standards and an evaluation instrument to guide medical schools in their implementation efforts. The AAMC argued that simply adding cultural competence to the medical school curriculum is not enough. Cultural competence education must be incorporated throughout the curriculum in order to avoid marginalizing the importance of it. The American Nurses Association (ANA) issued its first position statement regarding the inclusion of cultural diversity in nursing curricula in 1986. Five years later, the ANA (1991) endorsed their earlier position by stating that “knowledge of cultural diversity is vital at all levels of nursing practice” (paragraph 2). The ANA contends that information regarding health beliefs and practices should be included in all nursing curricula. This inclusion validates the importance of considering cultural beliefs and practices as a vital component of the nursing process. A number of other healthcare related organizations and agencies have proposed cultural competence curriculum standards. In 2003, The California Endowment, a private health foundation that supports grassroots efforts throughout the state to improve access to and quality of healthcare for underserved groups, established a set of principals and recommended standards for cultural competence education. The increasing number of diverse cultural groups introducing different beliefs of illness and healthcare prompted a need for The California Endowment to make considerable revisions to their curriculum in order to meet the changing needs of the patients they were serving.


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In 2005, the released a curriculum guide titled Transforming the Face of Health Professions Through Cultural and Linguistic Competence Education: The Role of the HRSA Centers of Excellence. This guide provides healthcare educators with resources and specific tactics to assist with the implementation and integration of CAL competency in academic programs. Although the guide is directed to educators in HRSA’s Centers of Excellence Program, it is widely applicable to other settings (HRSA 2005). This year, the OMH developed a website offering culturally competent curriculum modules and free resources and tools for both nurses and physicians (see www. thinkculturalhealth.org).

CAL Competence in Healthcare Management Curriculum A number of authors agree that the engagement and commitment of leadership is one of the most vital elements to successfully integrating cultural competence (Dreachslin 2007b; Raso 2006; Wu and Martinez 2006). Although CAL competence initiatives do not have to emerge from the top, full support and active involvement from leadership will result not only in the adoption of those initiatives, but it will increase the likelihood of full implementation throughout the organization. To become diversity and cultural competency champions, leaders must first uncover their own hidden biases. Dreachslin (2007b) argues that self-awareness is a powerful tool for healthcare leaders. “If a leader is aware of [his or] her own biases and is willing to acknowledge them, [he or] she can mitigate these biases’ impact on [his or] her decision making.” If left unchecked, biases can compromise quality and patient safety, and may result in unnecessary increase in costs (Dreachslin 2007b). Healthcare leaders must also create an atmosphere that fosters acceptance, education, and engagement and provides the resources necessary for the implementation and ongoing evaluation of cultural and linguistic competence. Gardenswartz and Rowe (1998) argue that leaders must “walk the talk.” The authors contend that it is not enough for healthcare leaders to go through the motions; rather their efforts must be sincere. If leaders do not believe in the importance of promoting and managing diversity, neither will the employees. Ultimately, leadership is “the glue that ties [cultural competence] all together” (Raso 2006). Moreover, as the healthcare workforce continues to diversify, leaders will also be challenged to understand, encourage, and manage a culturally diverse labor pool. Managing workforce diversity requires a strong commitment from organizational leaders to create and nurture an organizational

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culture that considers diversity as inherently good for the organization and the community (Ciccocioppo and Ciccocioppo 2002). Shaw-Taylor and Benesch (1998) argue that “valuing employees’ differences is intrinsically important, not only in the delivery of healthcare, but in the retention of quality healthcare providers who can best serve the growing diversity of the patient pool.” Spataro (2005) adds that as the composition of the workforce becomes more diversified, attitudes regarding diversity will change. She notes that employees who differ in gender, race, and ethnicity from others in the organization are generally more inclined to adjust their behaviors to conform to different situations. In addition, Dansky, et al (2003) note that “culturally diverse organizations outperform their more homogeneous counterparts.” Increasing workforce diversity, therefore, can result in greater access to care, improved patient-physician communication and relationship, compliance with treatment and follow-up, larger market share, higher productivity, and increased patient and provider satisfaction (Spataro 2005; Maxwell 2005). There are, however, costs associated with diversity management. Dansky, et al (2003) state that “diversity management practices create additional costs stemming from increased coordination and control” and may not be ideal for organizations emphasizing cost effectiveness. Initially, workforce diversity may result in emotional conflict within teams due to differences in beliefs, practices, and perspectives. This conflict, however, can be diffused by investing in professional development. Leaders can maximize performance by providing individuals with the knowledge and skills needed to understand that cultural differences benefit the organization by offering different points of view. (Dreachslin 2007b). Figure 1 presents a conceptual model depicting the inter-relationship between organizational leadership and the clinical staff in producing positive outcomes by providing CAL appropriate care. Leadership is charged with effectively managing diversity and adopting the role of diversity champion through a set of cultural competencies. The clinical staff is charged with providing care that is CAL appropriate through an expanded set of competencies (adopted from Campinha-Bacote’s Model of Care 2002). The double-ended arrow between the organization leadership and the clinical staff illustrates the ongoing communication that must exist in order to sustain competency efforts. Leadership must constantly be aware of the changing needs of its service area and the needs of the clinical staff. It is imperative that clinical staff receive the necessary training and resources to provide care that is congruent with a patient’s beliefs, practices, and expectations. The provision of CAL appropriate care results in positive outcomes not only


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for patients, but for the clinical staff and the organization as well. Soliciting feedback from patients and employees allows both leaders and clinical staff to identify areas of improvement. Figure 1. Provision of Culturally and Linguistically Competent Services: An Organizational Model Figure 1. Provision of Culturally and Linguistically Competent Services: An Organizational Modela Outcomes Organizational Leadership Effectively manage diversity and adopt the role of diversity champion through: Cultural Awareness Cultural Knowledge Cultural Skills

Evaluation/Customer and Employee Feedback

Provision of Culturally and Linguistically Appropriate Care Clinical Staff Cultural Awareness Cultural Knowledge Cultural Skills Cultural Encounter Cultural Desire (Campinha-Bacote 2002)

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Evaluation/Customer and Employee Feedback

Patient: Improved access and utilization Increased trust and acceptance Greater compliance with physician directives True informed consent Active participation in treatment Clinical Staff: Greater diversity among staff Less confusion and frustration Positive patient-clinician encounter Appreciation of differences Organization: Greater market share Increased labor pool Decrease in employee turnover More effective teams Higher productivity Provision of equitable care Improved quality of care Improved customer and employee satisfaction Less costly diagnostic tests Decrease in liability

The Clinical Staff portion of the model adopted from Campinha-Bacote (2002).

Proposed Competencies for Healthcare Management Majors The need to be CAL competent, however, extends beyond clinicians. Healthcare managers must also be aware of cultural and language differences, and understand the role that CAL competence plays in eliminating healthcare disparities, broadening access, and reducing the number of costly diagnostic procedures. Integrating CAL competency content throughout a healthcare management curriculum legitimizes the topic by including it in what Eisner (1994) refers to as the explicit curriculum, or what is formally taught. According to HRSA (2005), “ignoring cultural and linguistic competence makes it part of the null curriculum, meaning that if a school does not teach it, it is ignoring it.” Based on the discussion of the importance of managing diversity and ensuring the provision of CAL appropriate care, proposed competencies for healthcare management students are presented in Table 1. The authors adopted the three main learning objectives areas used by HRSA (2005) guide Transforming the Face of Health Professionals Through Cultural and Linguistic

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Competence Education: The Role of HRSA Centers of Excellence. These areas include: (1) cultural awareness and attitude; (2) cultural skills; and, (3) cultural knowledge. The competencies outlined within each area, however, were developed by the authors and correspond to the roles and responsibilities of healthcare leaders. The proposed competencies are intended to promote cultural self-awareness and address the biases, prejudices, and assumptions that students may have towards individuals with different cultural and language backgrounds. These competencies also seek to equip healthcare management majors with the knowledge and skills necessary to develop and nurture culturally and linguistically competent organizations. Figure 2: Cultural and Linguistic Competencies for Healthcare Management Majors Goals for Cultural Awareness and Attitude 1. Awareness of one's own biases, prejudices, and assumptions towards individuals of a different culture and/or limited English proficient (LEP), 2. Appreciate cultural differences, 3. Develop empathy and respect for individuals who are of a different culture and/or are LEP.

Goals for Cultural Skills Development Organizational Leadership Effectively manage diversity and adopt the role of diversity champion through: Cultural Awareness and Attitude Cultural Skills and Development Cultural Knowledge

1. Effectively manage diversity, 2. Conduct organizational assessment, 3. Create and nurture a mission and a vision of cultural and linguistic competence, 4. Develop policies and procedures, 5. Allocate the necessary resources, 6. Conduct ongoing evaluation, 7. Maintain direct leadership involvement, 8. Develop recruitment and retention measures to attract and retain a diverse staff.

Goals for Cultural Knowledge 1. Understand the role of culture in health, 2. Understand of the importance of communication in health care, 3. Knowledge of underserved populations and the barriers they face, 4. Knowledge of the disparities in health and health care among minority groups, 5. Knowledge of the changing demographics and its implications for the patient population and the health care workforce, 6. Understand the importance of a recruiting and retaining a diverse workforce as well as the challenges that come with managing a diverse workforce, 7. Understand the benefits of using a trained medical interpreter, 8. Knowledge of federal, state, and professional mandates related to cultural and linguistic competence including National Standards for Culturally and Linguistically Appropriate Standards in Health Care.


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Table 2. Learning Objectives and Core Competencies Related to Culturally and Linguistically Appropriate Services for Health Care Management Majors Learning Objective

Competencies

Cultural Awareness and Attitude: Students competent in this domain

• Recognize the personal biases, prejudices, and assumptions they may have towards individuals that are of a different culture and/or speak a different language • Recognize the value that cultural differences bring to the organization • Demonstrate empathy and respect towards individuals who are of a different culture and/or speak a different language • Understand the role of culture in health and health care • Understand the importance of communication in health care and the benefits of eliminating language barriers • Recognize the importance of assessing the organization’s service area to determine underserved groups • Recognize the importance of allocating the necessary training and resources • Are aware of the various federal, state, and professional mandates related to cultural and linguistic competence

Cultural Skills: Students competent in this domain

• Demonstrate how to forecast cultural and linguistic demands • Demonstrate how to conduct a cultural assessment of the organization • Demonstrate how to make use of community resources • Demonstrate how to effectively manage diversity • Demonstrate how to effectively use a medical interpreter • Foster an organizational culture that values differences

Cultural Knowledge: Students competent in this domain

• Understand the impact that culturally and linguistically appropriate services have on quality and cost • Understand the impact that culturally and linguistically appropriate services have on health outcomes, patient satisfaction, and employee satisfaction • Are familiar with the beliefs, practices, and traditions of the various cultural groups present in their service area • Understand the importance of recruiting and retaining a diverse workforce • Understand the importance of linking the provision of culturally and linguistically appropriate services to organizational policies and procedures

Possible Assignments and Activities A number of examples, media, and activities can be used to emphasize the importance of providing CAL appropriate services. For instance, students in an introductory course may be asked the role play the parts of a patient and physician. The purpose of the exercise is to help students better understand

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the challenges faced by individuals experiencing a cultural or language challenge and develop empathy. Each student is given a note card listing a well-known illness or disease and a few of the most common symptoms associated with the disease. The students are instructed not to speak when playing the role of the patient and to use only nonverbal gestures to demonstrate their symptoms and have their counterpart (the provider) guess their illness or disease. Another possible modification might be to have the patient use nonspecific or vague language indicative of cultures in which communication is often indirect. For example, in some Chinese cultures, emotional responses such as depression are described using physical terms such as a pain in the chest (Han, et al 2005). After the activity, the students can be asked how they felt not being able to communicate verbally or with expected precision, both as the patient as well as the provider. Students in courses related to managing healthcare organizations can be shown a segment of a video created by the Federal Interagency Working Group on Limited English Proficiency (see www.lep.gov). Maintained by the U.S. Department of Justice, this website provides information to federal agencies, recipients of federal funds, community organizations, and individuals on the implementation of and compliance with language access services for limited English proficient customers. A segment of the video titled Breaking Down the Language Barrier: Translating Limited English Proficiency into Practice shows two scenarios depicting an injured, limited English proficient man seeking help at a hospital. The first scene reviews the barriers to providing care due to the lack of an interpreter; the second scene replays the scenario with an interpreter available. After watching the video clip, students can be asked to compare and contrast the two scenarios. Faculty may also want to solicit student ideas/thoughts on how and why the second scenario would result in greater accessibility, higher quality of care, increased customer and employee satisfaction, lower costs, better accrediting compliance, and overall reduced facility liability. Additionally, students may be asked for reasons why a facility may be opposed to a staff interpreter and for their ideas on creative methods facilities can use to meet the needs of limited English proficient patients. Faculty may take this opportunity to emphasize the additional benefits of providing language access services and culturally competent care beyond complying with legislative and professional mandates or solely as a means to limit liability. Moreover, the students can be asked to discuss the implications of these situations for the organization and the healthcare manager. Students should


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be encouraged to consider the role of management in providing appropriate structures for providers to effectively deliver quality care. Additionally, the class discussion can include information on the type of data that would be needed in order to determine if the volume of limited English proficient patients warrant the hiring of a staff interpreter or outsourcing this service. Furthermore, faculty may want to have students discuss the issue of breaching the provider/patient relationship in order to ascertain when a CAL challenge may exist. Faculty may want to ask students to consider the possible responses by providers to this type of managerial oversight. Finally, some additional discussion questions might include: (1) the possible negative consequences for the patient and how to best mitigate them; and (2) as future healthcare leaders, what is their role in anticipating, identifying, and preventing encounters such as these? Faculty may also consider having their students read “The Spirit Catches You and You Fall Down” by Anne Fadiman (1998) as a supplemental reading. Fadiman recounts the true story of a Hmong family living in California in the early 1980s whose infant daughter suffers from epilepsy. The author reviews the series of cultural misunderstandings and language barriers that occurred between the family and their American doctors which ultimately resulted in the child suffering a massive seizure and being left in a vegetative state. This assignment may be appropriate for healthcare policy courses. Class discussions may focus on legislative efforts to prevent tragedies such as this from occurring. Executive Order Limited English Proficiency (LEP) should be reviewed along with the National Standards on Culturally and Linguistically Appropriate Services in Healthcare (CLAS). The CLAS standards, developed by the DHHS-OMH in 2001 in response to LEP, are intended to serve as a guide for healthcare organizations in providing care that is both culturally congruent and in their proficient language. Students should be made aware that the standards pertaining to language access services (Standards 4-7) are mandated by the LEP law. Discussions may also focus on how LEP and the CLAS standards contribute to the efforts to broaden access and eliminate disparities in health and healthcare for minority populations. A number of websites offer cultural competence learning modules and case studies that can be used in various healthcare management courses. A collaborative project developed by several academic pediatric pulmonary centers and funded by the HRSA Maternal and Child Health Bureau provides online cross cultural healthcare case studies, corresponding lectures, and learning activities (see http://support.mchtraining.net/national_ccce/index. html). CulturalDiversity.org, a non-profit organization that seeks to increase

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awareness of transcultural nursing issues and promote cultural diversity, offers basic health and healthcare related concepts and case studies on various different cultural groups (see www.culturaldiversity.org/cases). A case study and commentary focusing on language barriers can be found on AHRQ’s WebM&M (Morbidity and Mortality Rounds on the Web) website (see www.webmm.ahrq.gov/ case.aspx?caseID=123). In analyzing these case studies, faculty may ask students to identify the problem, discuss the implications for the patient, clinician, staff, and organization, and recommend solutions.

Conclusions As our nation’s population continues to diversify, healthcare leaders will increasingly be faced with the difficult and often daunting task of managing workforce and patient diversity. Providing future healthcare leaders with the knowledge and skills necessary to effectively meet the challenges associated with developing and maintaining a CAL-competent organization will help to lessen the health disparities and barriers to access that patients with limited English skills may face. Incorporating cultural and linguistic competencies in a healthcare management curriculum may be difficult for faculty that are not yet familiar with cultural and linguistic competence in healthcare. Similar to how healthcare leaders should be sincere in their efforts to develop CALcompetent organizations, faculty should also be sincere in their efforts to develop CAL-competent healthcare management students. By helping students to understand the wide-reaching implications of CAL barriers for the organization and the healthcare system, graduates of healthcare management programs will be better prepared to help move the industry toward improved care delivery.

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Association of American Medical Colleges. (2006). Diversity in the Physician Workforce: Facts and Figures 2006. Washington, D.C.: Association of American Medical Colleges. Association of American Medical Colleges. (2005). Cultural Competence Education. Washington, D.C.: Association of American Medical Colleges. Baker, D. W., Hayes, R. & Fortier, J. P. (1998). Interpreter Use and Satisfaction with Interpersonal Aspects of Care for Spanish Speaking Patients. Medical Care, 36(10), 1461-1470. Baker, D. W., & Parker, R. M. (1996). Use and Effectiveness of Interpreters in an ER. JAMA, 275(10), 783-788. Betancourt, J. R., Green, A. R., Carrillo, J. E., & Park, E. R. (2005). Cultural Competence and Health Care Disparities: Key Perspectives and Trends. Health Affairs, 24(2), 499-505. California Endowment. (2003). Principles and Recommended Standards for Cultural Competence Education of Health Care Professionals. Woodland Hills, CA: The California Endowment. Campinha-Bacote, J. (2002). The Process of Cultural Competence in the Delivery of Health Care Services: A Model of Care. Journal of Transcultural Nursing, 13(3), 181-184. Carrasquillo, O., Orav, E., Brennan, T., & Burstin, H. (1999). Impact of Language Barriers on Patient Satisfaction in an ER. Journal of General Internal Medicine, 14(2), 82-87. Ciccocioppo, M. V., & Ciccocioppo, M. J. (2002). Practitioner Application. Journal of Healthcare Management, 47(2), 124-126. Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Toward a culturally competent system of care, volume I: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center. Dansky, K. H., Weech-Maldonado, R., DeSouza, G., & Dreachslin, J. L. (2003). Organizational Strategy and Diversity Management: Diversity-Sensitive Orientation as a Moderating Influence. Health Care Management Review, 28(3), 243-253. Denboba, D. (1993). MCHB/DSCSHCN Guidance for Competitive Applications, Maternal and Child Health Improvement Projects for Children with Special Health Care Needs. U.S. Department of Health and Human Services, Health Services and Resources Administration. Dobson, S. M. (1991). Transcultural Nursing: A Contemporary Imperative. London: Scutar Press. Dreachslin, J. L. (2007a). A Systems Approach to Culturally and Linguistically Competent Care. Journal of Healthcare Management, 52(4), 220-226. Dreachslin, J. L. (2007b). Diversity Management and Cultural Competence: Research, Practice, and the Business Case. Journal of Healthcare Management, 52(2), 79-86.

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Dreachslin, J. L. (1996). Diversity Leadership. Chicago: Health Administration Press. Eisner, E. (1994). The Educational Imagination: On the Design and Evaluation of School Programs. New York: Macmillan College Publishing. Ferguson, W. J., & Candib, L. M. (2002). Culture, Language, and the Doctor-Patient Relationship. Family Medicine, 34(5), 353-361. Gardenswartz, L., & Rowe, A. (1998). Managing Diversity in Health Care. San Francisco: Jossey-Bass. Giger, J. N. & Davidhizar, R. E. (2002). The Giger and Davidhizar Transcultural Assessment Model. Journal of Transcultural Nursing, 13(3), 185-188. Hampers, L. C., Cha, S., Gutglass, D. J., Krug, S. E., & Binns, H. J. (1999). Language Barriers and Resource Utilization in a Pediatric ER. Pediatrics, 103(6), 1253-1256. Herndon, E., & Joyce, L. (2004). Getting The Most From Language Interpreters. Family Practice Management. Retrieved April 6, 2007, from http://www.aafp.org/fpm Institute of Medicine. (2002). Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academy of Sciences. Joint Commission on Accreditation of Healthcare Organizations. (2005). Joint Commission 2005 Requirements Related to the Provision of Culturally and Linguistically Appropriate Health Care. Retrieved June 2, 2007, from http://www.jcaho.org/about+us/hlc/hlc_jc_stds.pdf Han, J., Zhu, Y., Li, S., & Chen, X. (2005). Respiratory Complaints in Chinese: Cultural and Diagnostic Specificities. Chest, 127(6), 1942-1951. Kim-Godwin, Y.S., Clarke, P. N., & Barton, L. (2001). A model for the delivery of culturally competent community care. Journal of Advanced Nursing, 35(6), 918-925. Ku, L., & Flores, G. (2005). Pay Now or Pay Later: Providing Interpreter Services In Health Care. Health Affairs, 24(2), 435-444. Leininger, M. (1995). Transcultural Nursing: Concepts, theories, research and practices. New York: McGraw-Hill. Leininger, M. M. (1978). Transcultural Nursing: Concepts, Theories, and Practices. New York: John Wiley & Sons, Inc. Maxwell, M. (2005). It’s Not Just Black and White: How Diverse Is Your Workforce? Nursing Economics, 23(3), 139-140. Medrano, M. A., Setzer, J., Enders, S., Costello, R. M., & Benavente, V. (2005). Self-Assessment of Cultural and Linguistic Competence in an Ambulatory Health System. Journal of Healthcare Management, 50(6), 371-387.


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National Center for Cultural Competence. (2004). Definition and conceptual framework of cultural competence. Retrieved April 2, 2007, from http://gucchd.georgetown.edu/nccc/ framework.html National Committee for Quality Assurance. (2001). MBHO Surveyor Guidelines. Retrieved April 7, 2007, from http://www.ncqa.org/docs/policies/mbho/attach2-qi6.pdf Purnell, L. D. & Paulanka, B. J. (2003). Transcultural Health Care: A Culturally Competent Approach. Philadelphia: F.A. Davis. Raso, R. (2006). Cultural Competence: Integral in Diverse Populations. Nursing Management, 37(7), 56. Shaw-Taylor, Y., & Benesch, B. (1998). Workforce Diversity and Cultural Competence in Healthcare. Journal of Cultural Diversity, 5(4), 138-146. Spataro, S. E. (2005). Diversity in Context: How Organizational Culture Shapes Reactions to Workers with Disabilities and Others Who are Demographically Different. Behavioral Sciences and Law, 23(1), 21-38. Spector, R. E. (2004). Cultural Diversity in Health and Illness. New Jersey: Pearson Prentice Hall. Suh, E. E. (2004). The Model of Cultural Competence Through an Evolutionary Concept Analysis. Journal of Transcultural Nursing, 15(2), 93-102. U.S. Census Bureau. (2005). 2005 American Community Survey. Retrieved April 8, 2007, from http://factfinder.census.gov/servlet/ACSSAFFFacts?_event=&geo_ id=04000US01&_geoContext=01000US%7C04000US01&_street=&_county=&_cityTown=&_state=04000US01&_zip=&_lang=en&_sse=on&ActiveGeoDiv=&_useEV=&pctxt= fph&pgsl=040&_submenuId=factsheet_1&ds_name=DEC_2000_SAFF&_ci_nbr=null&qr_ name=null®=&_keyword=&_industry= U.S. Census Bureau. (2003). The Foreign-Born Population: 2000. Retrieved April 8, 2007, from http://www.census.gov/prod/2003pubs/c2kbr-34.pdf U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. (2003). What is Cultural and Linguistic Competence? Retrieved June 23, 2007, from http://www.ahrq.gov/about/cods/cultcompdef.htm U.S. Department of Health and Human Services. Health Resources and Services Administration. (2005). Transforming the Face of Health Professions Through Cultural and Linguistic Competence Education: The Role of HRSA Centers of Excellence. Rockville, MD: Bureau of Health Professions. U.S. Department of Health and Human Services. Health Resources and Services Administration. (2006). The Registered Nurse Population: Findings from the March 2004 National Sample Survey of Registered Nurses. Retrieved May 16, 2007, from ftp://ftp.hrsa.gov/ bhpr/workforce/0306rnss.pdf.

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U.S. Department of Health and Human Services. Health Resources and Services Administration. (n.d.). Programs, Diversity, Other Definitions of Cultural Competence. Retrieved April 8, 2007, from http://bhpr.hrsa.gov/diversity/cultcomp.htm U.S. Department of Health and Human Services. Office of Minority Health. (2001). A Practical Guide for Implementing the Recommended National Standards for Culturally and Linguistically Appropriate Services in Health Care: First Draft. Retrieved March 2, 2007, from http://www.omhrc.gov/clas/guide3a.asp Whitman, M. V., & Davis, J. A. (2008). Cultural and Linguistic Competence in Healthcare: The Case of Alabama General Hospitals. Journal of Healthcare Management, 53(1), 26-40. Wu, E., & Martinez, M. (2006). Taking Cultural Competency From Theory to Action. Retrieved April 7, 2007, from http://www.commonwealthfund.org/usr_doc/Wu_takingcultcomptheoryaction_964.pdf?section=4039