The Role of Cultural Competence in Delivering Positive Patient Experiences

Sahar Andrade, MB.BCh Sahar Consulting, LLC Jason A. Wolf, Ph.D. The Beryl Institute

Improving the patient experience

The Beryl Institute serves as the professional home for stakeholders who recognize that the patient experience is an essential element in the execution and evaluation of health care performance. The Institute is committed to improving the patient experience, by serving as a reliable resource for shared information and proven practices, a dynamic incubator of leading research and new ideas and an interactive connector of effective leaders and dedicated practitioners. The Institute is uniquely positioned to develop and publicize cutting-edge concepts focused on improving the patient experience, touching thousands of healthcare executives and patients. The Institute defines the patient experience as the sum of all interactions, shaped by an organizations culture, that influence patient perceptions across the continuum of care. You can follow The Beryl Institute on LinkedIn, Facebook and Twitter (@berylinstitute) or visit www.theberylinstitute.org.
2011 The Beryl Institute

Setting the Context

This white paper visits the importance of cultural competence and cultural sensitivity in the healthcare sector and how it impacts the experience of patients, their families and support groups. All too often the patient experience is seen as WHAT is done to or for patients and much less about HOW or even WHY. In the healthcare setting human beings are often found at their most vulnerable. Beyond their expectation of healing, they are looking for nothing more than a caring gesture, comforting look or kind word. What must be realized is that these simple desired actions are not in fact the same for everyone. To support the key points in this paper, a few generalizations will be made. This is not to glance over a topic or not to pay it full attention, but rather it is an important place to begin the critical exploration of the issue of cultural competence. Generalization is a starting point in indicating common trends and patterns or recognizing beliefs and behaviors shared by a certain group. They make it just a bit easier to study and understand a culture. There is a subtle, but important difference between generalization and stereotyping. While generalizing can be used in a positive manner, stereotyping, which may feel similar, functions very differently, and can negatively influence interpersonal interactions. Stereotyping represents an end point and can be defined as the process by which people acquire and recall information about others based on their race, sex, religion, etc. Stereotyping has its roots in prejudice, that is that one may in fact pre-judge people, having certain predetermined expectations and an unjustified negative attitude based on a persons group or class identity. That attitude is acquired either through past personal experiences or through preconceived and often incorrect beliefs. It leads to the development of a specific attitude, concept, opinion, or belief about a person or group and as a result influences the very actions one may take in interacting with certain people. A stereotype is a mental picture developed and perpetuated as a result of a myth. People do not often realize the manifestations of their own biases and or prejudices toward others. This is an important recognition, as this is not always done in a conscious or malicious way. Often, these mental models, shaped by our experiences, are carried with us unknowingly or at least with a lower level of awareness. Yet it is important to find ways to raise our own awareness, as it is these very stereotypes that can influence the way we engage in and shape the patient experience in our healthcare settings. To better understand the subtle difference, if one assumes that all people perceived to be Middle Eastern are Muslims, this is stereotyping, as a good percentage are also Christian, Jewish, Druze or Bahai. Rather if one asks if someone perceived to be Middle Eastern is Muslim, but does not base actions in this inquiry, this is a generalization. This difference is crucial as the former sets our path of action before inquiry; the latter moves from inquiry to action. That simple shift can make all the difference. This issue is highlighted to open this paper, for while often unseen, it becomes a crucial element in the very delivery of the entire care experience. It is important that healthcare providers raise awareness to the importance of cultural competence and sensitivity. In doing so the industry can address medical practice in a way that acknowledges what can happen to the care offered and the overall experience provided when it fails to recognize individual differences, when stereotype is placed above generalization, and when action is put before inquiry. The Beryl Institute defines the patient experience as the sum of all interactions, shaped by an organizations culture, that influence patient perceptions across the continuum of care. This touches the very heart of this issue. While being conscious of patients perceptions and the foundational culture in which a healthcare organization operates, it must be aware of perceptions that influence work and the cultures of individual patients, families and support networks that are encountered every day. It is here where cultural competence can be used as a key to ensure a positive patient experience.

Acknowledging Diversity
In todays global environment, especially in the United States, cultural diversity is becoming a way of life that cannot be ignore. While diversity includes some protected classes by law, such as minorities, women, sexual orientation, disabilities, etc., the concept of diversity reaches well beyond protected categories to encompass all characteristics that make an individual unique. It includes education, socio-economic factors, titles, jobs, abilities and disabilities, marital and parental status, geographical location, and more. Each diverse group possesses their own culture. Yet, things get even trickier as there is also a need to be aware of individual differences. Culture and diversity are central to everyday behaviors, attitudes, perceptions, and interactions between people. Acknowledging differences helps us to understand how both culture and diversity have a significant impact on how people perceive and react to healthcare providers attitudes, diagnosis, and treatment and ultimately reflect on their experience overall. Cultural awareness in healthcare has its advantages as it strengthens the bond between the patients and the providers and also has the potential to increase cooperation and teamwork within the provider workforce. Ignoring this issue can have a number of potential

Factors that can impact the relationship between patients and health providers
Communication and interpersonal relationship styles including word choice, voice tone and volume, eye contact, and proper titles Gender issues and consideration of appropriate male/female interaction Age, respect, and seniority Individualism and equality Clothing, hair styles, and body adornment Informal and social interactions Language spoken/use of interpreters or family members

negative effects, from disrupting the relationship between patients and providers, to creating mistrust and miscommunication, both which can result in a diminished care experience or even in legal consequences that can have a substantial financial impact due to miscommunications or even perceived malpractice.

US Population Projections to 2050

Percentage by race and Hispanic origin

Source: US Census Bureau

14.2 6.8 21.2 14.3 7.3 23.0 14.5 7.8 24.8 14.7 8.3 26.7 14.8 8.8 28.7 15 9.2 30.3

100 90 80 70 60 50 40 30 20 10 0

13.6 5.3 16.0

13.8 5.8 17.7

14 6.3 19.4

64.7

62.4

60.1

57.8

55.5

53.1

50.8

48.5

46.3

2010

2015

2020

2025

2030

2035

2040
Hispanic

2045

2050

Black including mixed race

Asian including mixed race

White non-Hispanic

The Role of Cultural Competence in Delivering Positive Patient Experiences

Why is Cultural Competence Important?

Over the past decade, the importance of cultural competence as a critical facet for the provision of high quality health care has risen. As such, cultural competence has been defined in the context of healthcare delivery, specifically focusing on the provider-patient interaction. According to the US Department of Health and Human Services, Office of Minority Health, cultural competence is: A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in crosscultural situations. Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. They also stress its importance as outlined above stating: Cultural competency is one of the main ingredients in closing the disparities gap in health care. It is the way patients and doctors can come together and talk about health concerns without cultural differences hindering the conversation, but enhancing it. Quite simply, health care services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients can help bring about positive health outcomes. The issue of cultural competence and awareness is critical due to the increasingly changing demographics both in the United States and around the world. This results in diverse patient populations from different racial, ethnic, socioeconomic, religious, and cultural backgrounds. Today, in the United States, 27% of the total population is an ethnic and/or racial minority. In addition, 12.6% of the total U.S. population is foreign born; of these, 53.6% are from Latin America and 26% are from Asia (according to the 2007 American Community Survey).

While these numbers are not the primary reason why cultural competence is important to experience, they are important to consider as key factors in why those in healthcare need to be cognizant of and prepared to manage an increasingly diverse patient population. Some facts to consider:

By 2050, todays minorities will become the majority in the United States. It is also important to add the additional expanding communities that are appearing in the 2010 US census including Armenians and people from Middle Eastern countries. One million immigrants enter the United States legally every year. Coming from every continent, their ability to speak and understand English varies from minimal to fully fluent. Five generations now currently interact in the workplace. These generations have different cultural frameworks, communications skills and work styles. Under-represented groups form almost 34% of the total US population, yet the healthcare workforce has not kept up with these changing demographics, For example physicians from under-represented groups make up only about 7% of the current workforce, nurses 3% and pharmacists 3%. This creates the potential for significant communication and cultural barriers. Changing family demographics are also influencing the patient population experience in healthcare settings from ethnically or racial mixed and same-sex couples, to stay-at-home dads and grandparents as caregivers.

As the diversity of the population increases, so does its cultural complexity. This growth in differences also expands the sets of beliefs, values, perceptions, and communication styles and skills that patient populations bring. With that the importance of understanding cultural diversity and competence in healthcare is crucial. This is especially true if the main job of any healthcare provider is to ensure that patients trust them, can openly discuss their problems, and follow their treatment as prescribed. Providers must be aware of the vulnerability of patients and their families in these circumstances.

So what are the potential variables? Among others, they include beliefs, values, communication styles, gender issues, family hierarchy, religion, education, expression of pain, accepting death and dealing with terminal diseases, birth, pregnancy, time-orientation as well as language barriers. Each of these adds a layer of complexity, but plays a crucial role in the experience of patients today. If the healthcare provider is equipped with greater knowledge of the patients culture, respects them and knows how to work within the parameters set by their values, this will have a positive impact on the care and service they provide and a significant influence on the overall patient experience.

different groups communicate and relate to one another, and they carry over into interactions with healthcare providers. According to the JCAHO requirements HR.01.04.01 (the hospital provides orientation to staff), item EP5 specifies that a hospital must orient staff on the following: Sensitivity to cultural diversity based on their job duties and responsibilities and that completion of this orientation be documented. Even with this requirement, it is important to consider that cultural sensitivity does not only mean that a person be aware of differences to interact effectively with people from other cultures. They should also take the steps necessary to recognize their own cultural values and potential biases wherever possible. This self-awareness becomes part of the very equation for success. To be culturally competent providers should not be expected to have full knowledge of every cultural practice and belief. Rather they must be sensitive to the preferences and values of others, and should not assume that one persons preferences and values apply to everyone in that same group. It is not in needing to know everything about every culture, but rather in having the awareness that patients beliefs may be different from the caregiver, that provides the opportunity to be more sensitive and aware and ensure the best experience possible. In addition, dealing with every patient as a unique individual with special experiences, beliefs, values, language and perceptions moves well beyond experience. It has the potential to increase the odds of the patients acceptance of the clinical service delivery, understanding of the diagnosis, and ultimately compliance with their plan of care. Cultural competence doesnt simply make the experience better, it allows for the best outcomes for the patient overall.

To be culturally competent providers should not be expected to have full knowledge of every cultural practice and belief.

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) offers accreditation to healthcare organizations that comply with Joint Commission standards and continuously make efforts to improve the care and services they provide. The JCAHO mission is To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. One of the keys in maintaining accreditation with JCAHO is to increase the ability to recruit and retain high performing staff members who provide the high quality care patients need and deserve. A core expected quality of staff is to be culturally sensitive and this begins with the recognition that there are differences between cultures. These differences are reflected in the way that

The Role of Cultural Competence in Delivering Positive Patient Experiences

Some Helpful Defintions

Before discussing ways of addressing cultural competence and diversity in healthcare, it important to review the key terms that play a part in this conversation. They include:
1. 7.

(both verbal and nonverbal) is used in a way that reflects sensitivity and appreciation for the diversity of others. Cultural Competence: As defined by the Department of Health and Human Services, Cultural Competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.

Ethnicity: Sharing a sense of identity with a particular religious, racial or national group. Race: A biological concept that defines groups of human beings based on a set of genetically transmitted characteristics. Note: Race and ethnicity are often confused; race refers primarily to physical attributes while ethnicity has specific attributes that exceed the limitation of the definition of race.

2.

3.

Culture: The collective programming or wiring of the human mind acquired over time that distinguishes the members of one human group from another through their behaviors that include self worth and esteem, thoughts, communication, action, values, and beliefs and that also guide decision making. Culture to a group is personality to an individual. Culture is the group identity. Culture is a learned characteristic and transmitted through families, organizations and other social groups. Diversity: The human qualities that make each person unique and differentiate us from others. Dimensions of diversity include: age, ethnicity, gender, physical abilities/qualities, disabilities, race, sexual orientation, educational background, geographic location, immigration status, income, marital and parental status, military experience, parental status, religious beliefs, work experience, political views, urban versus rural life, and job classification. Cultural Awareness: To be knowledgeable about ones own thoughts, feelings, beliefs and sensations as well as the ability to reflect on how these can affect ones interactions with others. Cultural Sensitivity: The recognition that there are differences between cultures, reflected in the ways they communicate and relate to one another, and how individuals interact with others. Cultural sensitivity is experienced when neutral language

4.

The perception or reality of discriminatory practices can result in significant internal conflicts and have lasting cultural effects.

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6.

Areas of Cultural Sensitivity

Some areas of human diversity and variation are viewed as evident in all cultural groups, the most obvious ones are: Communication. The basic components of the communication process are mainly universal, but vary among culture-specific groups in terms of language or dialect spoken, pitch, volume, pronunciation, use of silence, and use of body/nonverbal communication. Language/Reading Proficiency. When English is the patients second language the probabilities of misunderstanding and miscommunication become higher. For example a Mexican male boy was brought to the Emergency Room unconscious, his family explained his case as intoxicado, which means nauseated in Spanish, but the staff assumed he was intoxicated by either alcohol or drugs, and treated on that basis, only made the patient sicker. His younger brother who was born in the United States explained the meaning of the word after a day had passed. The hospital was sued for malpractice. In another example, most indigenous languages do not include a word for cancer. Thus when discussing prevention and early detection, specialists advise replacing the word cancer with health, such as breast health screening. Personal Space: In cultures like the United States, personal space is respected and if encroached can be considered threatening; in other cultures like Middle Eastern cultures, getting close to a person and touching them indicates closeness and friendliness. The cultural aspect of space determines the degree of comfort one feels in proximity to others, in body movement, and in perception of personal, intimate, and public space. Touching: The meaning of a simple touch differs between individuals, genders, and cultures. In Mexico, for example being grasped on the arm by another man is a sign of friendship. To pull away is seen as rude. In Indonesia, to touch anyone on the head or to touch anything with ones foot is considered highly offensive. In Islamic culture a female patient cannot be touched by a male health professional so, for example, a male nurse cannot draw her blood. Also shaking hands between genders is also forbidden. Social Orientation. Components of social organization vary by culture with differences observed in what constitutes ones understanding of culture, race, ethnicity, family role and function, work, leisure, church, and friends in day-to-day life. Time. The United States culture is mono-chronic where time is money and focused primarily on one task at a time versus Hispanic, Asian, and Middle Eastern cultures, which are polychromic cultures where time is flexible, relationships come first then business, where many tasks are done at the same time. Perceiving, measuring, and valuing time are different across cultures. Cultures also may look at time with a focus either on the past, present or future, which influences their behavior. Most commonly those that value the past see that their power is more in the past than in the present and will tend to be conservative and traditional in their health approaches. Those that look at their present, do not plan for their future hence they will not follow preventive measures to keep themselves well. Those more oriented to look at the future, believe in prevention so they keep healthy as they progress in life by exercising, proper diet, supplements, etc. Family organization. Egalitarian/ Hierarchical: they also vary in social structure. For example the United States culture follows to an egalitarian model, where everyone is supposed to be equal. Status and power of a person are based on the individuals achievements rather than gender or age or title. Other cultures, for example the Asian cultures, tend to follow a hierarchical model where status and power are based on gender, age, and occupation.

The Role of Cultural Competence in Delivering Positive Patient Experiences

Relationship to nature. People view nature as either being able to control it, being part of it, or having no control whatsoever on it. In the United States there is a belief that nature can be controlled, and because the body is part of nature, it can be controlled as well. In other cultures, such as Asian and Native American, people are seen as part of nature. Harmony with the earth is part of their life principles, hence the natural herbal treatments and remedies. In cultures, such as the Hispanic and Middle Eastern cultures, they believe that they have no control over nature, everything has been already decided so whatever will be will be. Preventive health care measures are likely to be ignored; they would do no good anyway. Eye contact/Gestures. Some cultures, such as the Hispanic and Asian cultures are humble, so they avoid direct eye contact as a sign of respect. In the Middle East, direct eye contact is the norm except between genders. Also smiling and nodding in certain cultures just means one is being polite and is not agreeing or even understanding. Consider the hand and head gestures as well, a head movement that means yes in a culture can mean no in another. An example of hand sign the represents OK in the United States is offensive in Brazil, means money in Russia and 0 in Japan.

Ethnicity/Country of Origin. Considering and portraying women is different in various cultures, for example, Hispanic Women, are often portrayed in movies, and novellas as being caregivers who tend to put the well-being of their families before their own. This attitude can contribute to a tendency not to take care of their health conditions in early stages. Philipino nurses in general are conservative in dispensing pain medication as in Philipino Catholic religion there is virtue in suffering. It is important to explain the proper administration of medicine oral, injection or local; as some countries sections believe that all medication are to be grinded to powder and applied locally. Do not assume that a patient will understand how to take the medication prescribed. Medicines are used in different ways in different countries, and confusion can result. Values, Beliefs & Customs. Understanding peoples values is a key to understanding their behavior, for our behavior generally reflects our values. In the Chinese culture the balance of yin and yang is extremely important to maintain ones health as they affect the body channels energy Qi. This becomes meaningful in administering medication for unless a prescribed medication fits that balance the patient might discontinue the medication without informing the physician. In Hispanic families,

respect must be conveyed at first to the father, then to the mother, then to the other older adults. Addressing the family members as Mr. and Mrs. is important as informal use of language will be seen as disrespectful and can also increase the level of suspicion. Spirituality. Each culture has its own degree of spirituality. For example the male Sikhs are not to shave their beards or any hair on their body even if needed for surgery. Taking a picture of some American Indian tribe members is not advised, as they believe that the picture takes the soul away, the remedy will be in family praying to get it back. Religion. Many behaviors and customs are regulated by religion. For example both conservative Jewish and Muslim patients will not accept the replacement of their mitral valve if acquired from pig tissue as both religions do not consume pork. In Islamic cultures, consider prescribing Insulin that has some pork ingredients only after explaining it to the patient and his or her families. Jehovah witnesses will not accept blood transfusion as it is against their religion, and they can sue any healthcare institution for battery if it is done against their will or without their knowledge and consent.

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What Happens When We Lack Cultural Competence

The cultural differences of both patients and providers affect healthcare beliefs, practices, and behaviors and influence the very expectations that patients and providers have of each other. Often in healthcare as in other sectors there is lack of awareness of these differences and their impact. The most common reasons often are:

The lack of awareness is magnified when looking at the patient-provider relationship. These relationships are affected when the understanding of each others expectations is missing as in the following examples:
1.

The provider may not understand why the patient does not follow instructions. Why does the family or the spouse, rather than the patient, make important decisions about the patients health care? The patient may reject the provider (and the entire system) even before any one-on-one interaction occurs because of nonverbal cues that do not fit expectations. The patient does not trust the provider or the whole institution if the doctor does not wear a white coat or is too casual calling the patient or their family members by his or her first names, or even smiling too much.

2.

3.

Lack of knowledge, resulting in an inability to recognize the differences Self-protection/denial, leading to an attitude that these differences are not significant, or that our common humanity transcends our differences Fear of the unknown or the new, because it is challenging and perhaps intimidating to understand something new that does not fit into ones world view Feeling of pressure due to time constraints, which can lead to feeling rushed and unable to look-indepth at an individual patients needs
4.

The lack of cultural competence in the healthcare workplace occurs at two central touch-points, (1) internally between the care providers themselves and (2) in the patient-provider relationship. At each of these touch-points there is the potential for significant impact. Challenging interactions between care providers can cause tension in the workplace. Unhappy employees cost an organization more than low productivity, high turnover or absenteeism, and loss of revenues. The perception or reality of discriminatory practices can result in significant internal conflicts and have lasting cultural effects.

These issues serve as samples of the multitude of potential challenges faced when we do not consider cultural competence as part of our experience plan. They also raise the level of importance for increasing cultural competence awareness in healthcare organizations overall. So where do you begin to engage staff on the critical issues of cultural competence?

A consistency in cultures across similar groups cannot be assumed, nor can a common culture across healthcare settings.

The Role of Cultural Competence in Delivering Positive Patient Experiences

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How Can We Begin to Address Cultural Competence?

Once you recognize the importance of culture competence as a critical part of your experience and care plans, you will then need to frame the kind of learning you want to put in place. Some critical focal points in providing cultural competence training should include:

Some Considerations When Addressing Cultural Competence

Cultural issues involve age, gender, education and socioeconomic status as well as ethnic, racial, and religious differences. Respect is a core value in all cultures therefore respect should be shown to the patient and family members at all times. Patients are human beings who have dignity and honor and are not just cases, diagnoses or bed numbers. Nods and polite smiles do not necessarily accomplish effective communication, and do not necessarily mean that the patient understood the diagnosis or treatment steps or even agree with the caregiver or physician. Medicine is a language that may require translation even for native English speakers due to the medical terminology. Medical decision-making may involve a family or community and not only the individual patient. Involve the hospital chaplain/local religious leader or the patients own religious leader when belief systems may affect healthcare decisions.

Recognize the value of and build respect for individual differences Understand basics of racial/ethnic distinctions and disparities Become familiar with a patient-based approach to cross-cultural care Improve communication skills and cooperation in cross-cultural patient interactions Improve cross-cultural communications between healthcare professionals themselves Increase awareness of personal cultures, values, beliefs Develop skills in interacting and responding to individuals from other cultures

Cultural competence is a developmental process. Beyond awareness of subtle expectations or assumptions, there is a need for knowledge about different cultural norms, lifestyle needs, and personal preferences of individuals from different groups. Some important topics to consider in building effective cultural competence learning opportunities include:

Adaptation of services to meet culturally unique needs Building culturally competent community partnerships Effective cross-cultural conflict resolution Effective cross-cultural communication Supervising a multicultural workforce Working effectively in diverse teams

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Framing a Cultural Competence Learning Program

When developing a learning program focused on cultural competence you should ask three central questions: what are we attempting to do, why are we doing this, and how do we plan to achieve it?
1.

take on massive interventions or training efforts that can overwhelm or even generate greater resistance to the learning process. Initially consider the basic steps to begin the critical dialog on why this topic is important and what it can do for your organization in impacting care and the patient experience. Starting with the basics also allows for greater buy in and broader understanding of what you are trying to accomplish. Once you have a framework of the what, why and how you look to proceed, consider engaging your staff in the basic knowledge of culture competence in healthcare. Aside from identifying what cultural competence is and how it impacts care as discussed above, some points to consider as examples and some common myths to address include:

What are we attempting to do? In its simplest form we are working towards nurturing an organizational culture that is grounded in understanding and respect. It is exemplified in how we express that respect for patients, patients families and support networks, and colleagues. Why are we doing this? As framed in the opening of this paper, there is a clear case to be made for the importance of cultural competence understanding in our healthcare environment. We must create the opportunity to understand the psychosocial, spiritual, and cultural values that are at play in the healthcare relationship and determine their impact on how we engage in the delivery of care and better understand the perspectives of patients, families and support networks. How we plan to achieve outcomes is critical, but also requires the willingness to have a simple and focused line of sight. To frame the how we must set clear objectives for the effort including goals for:

2.

Individual differences exist even within the same group of people. For example, children born in the United States to immigrant parents will carry the combined culture of his or her parents background and of the geography in which they grew up. Similar appearances do not necessarily mean people share the same culture. For example the diversity in the broad spectrum of Asian cultures based on both nationality (Japanese, Chinese, Korean, Thai, Vietnamese, and Cambodian, etc.) and family culture. Sharing a language or a nationality does not mean sharing the same culture. For example, people in the United States all speak English, but they come from numerous different cultures and backgrounds, so while they have many similarities, they also have vast differences. Sharing the same religion does not mean you share similar cultures. Even within religions you can experience a range of cultural beliefs and actions. For example, the cultural difference in Orthodox versus Reform Judaism or among the many denominations of Christianity.

3.

Patient/Doctor relationships Patient/Nurse relationships Patient/Staff relationships Doctor to doctor interactions Nurse to nurse interactions Staff interactions

In acting on the how it should be recognized that addressing cultural competence is a holistic effort that cannot engage one of these relationships without considering the others. For instance, simply creating cultural awareness of patients, but not addressing staff interactions leaves your entire effort incomplete and vulnerable. In framing a learning program you also need to determine where to start. All too often organizations

It is important to note that starting with simple concepts helps individuals build their own level of awareness and understanding in a way that is meaningful, lasting and has an impact on the very care experiences provided in healthcare.

The Role of Cultural Competence in Delivering Positive Patient Experiences

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Moving to Action
Acquiring cultural competence follows a very manageable set of steps. Maintaining a level of patience in progressing through these steps supports having cultural competence as an integral and ultimately successful component of your organizations experience efforts. The four suggested phases for putting your plan in motion include:
1.

steps that cultural competence can become an integral part of our patient experience efforts. In increasing cultural competence and using it as a key to providing a positive patient experience the ultimate goal should be a healthcare system and supporting workforce that can deliver the highest quality of care to every patient, regardless of race, ethnicity, cultural background, or language proficiency. To support the successful implementation of cultural competence practices there must be zero tolerance for discrimination or prejudice. Some additional keys to consider in supporting the success of your cultural competence efforts:

It starts with awareness. This includes addressing some of the simple concepts of difference, understanding the importance of this issue, the definitions that support it and some of the common concepts and even misperceptions that help frame it. It grows with knowledge. Based on your organization and its cultural surroundings what is the key knowledge you must have to ensure staff is focusing on the important issues? Being aware of what cultures you most often encounter and developing a solid foundation of general knowledge supports cultural competence success. It is enhanced by specific skills. Once the foundational awareness and general knowledge is in place, you can begin to develop core skills such as effective cross-cultural communication, conflict resolution, or working on diverse teams. By providing staff the key skills with which to engage patients you provide the foundation for continuously positive experiences. It is polished through cross-cultural interactions. Key to cultural competence success is moving beyond theory to practice. Understanding these ideas conceptually is much different than living them in practice. It is only through the application of these ideas in day-to-day interactions that one is both tested and behaviors refined. It is in the doing that cultural competence becomes a key factor in driving patient experience success.

2.

Recognize that cultural competence is not a standalone outcome but must be a part of every action across the continuum of care. Recruit and retain staff from various diverse groups. Instill feelings of acceptance and equality within the workforce that will reflect itself when dealing with patients. Increase awareness of different cultural communication skills and continuously train the staff on how to act with one another and with patients who are culturally different. Offer the services of a trained medical interpreter or develop a hospital language bank through multicultural staff. Ensure linguistic competency that extends beyond the clinical encounter to the appointment desk, advice lines, medical billing, and other written materials. Include family and community members in healthcare decision making.

3.

4.

To reiterate, to be culturally competent, caregivers and healthcare staff do not need to possess the extensive knowledge of every cultural practice and belief. Instead they should be sensitive to others preferences and values, and should not assume that one persons preferences and values apply to everyone in that same group. It is in starting with these very basic, but important

More so, healthcare organizations must engage staff and patients in determining the specific areas of focus most pertinent to each facility and identifying what it is that will support success. A consistency in cultures across similar groups cannot be assumed, nor can a common culture across healthcare settings. Most important is that every healthcare organization recognizes the true impact of this issue on both outcomes and experience and makes a conscious choice to act.

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Conclusion
Each person in the healthcare setting, whether a staff member, a patient or a family member, is a unique individual that in their own way brings a vast array of differences. This paper is not intended to suggest that healthcare has purposefully overlooked this fact, but rather it stresses that these differences may at times be taken for granted. The industry must act with intention to recognize differences for the strengths they bring, but also honestly for the potential intricacy they introduce to the healthcare environment. To improve the patient experience, cultural competence is one area in which we cannot fail to act. This paper has framed a number of key issues and offered a number of practices to explore around cultural competence. Below are some additional reflections that can become the catalyst for individual efforts:

Cultural sensitivity and competence begin with respect. Understanding another culture is a continuous process. One should make up their own mind about another culture only based on personal experience, not the words or stories of others. Stereotyping and even discrimination are often inevitable in the absence of cultural education and competence. Feelings of apprehension or lack of confidence are common when dealing with a different cultures. Recognizing and ultimately overcoming our own biases and prejudices is an ongoing effort.

To improve the patient experience, cultural competence is one area in which we cannot fail to act.

The final point is perhaps the most poignant. As much as organizations can plan for and train on cultural competence, it is a personal issue and a choice each person must make. Looking at cultural competence and the patient experience reveals the power of the personal relationships that are central to the healthcare process. It is about how each and every patient is impacted, and offered the care, kindness and respect they deserve. At the end of the day cultural competence, as with patient experience overall, is about choosing to do what is right in each individual case to positively impact every patient, family member and caregiver.

The Role of Cultural Competence in Delivering Positive Patient Experiences

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Resources and Laws on Patient Rights and Cultural Competence

Title VI Of The Civil Rights Act Of 1964 Title VI of the Civil Rights Act of 1964 is a national law that protects persons from discrimination based on their race, color, or national origin in programs and activities that receive federal financial assistance. If a person is eligible for Medicaid, other health care, or human services, they cannot be denied assistance because of race, color, or national origin. The Office for Civil Rights (OCR) in the U. S. Department of Health and Human Services (DHHS) enforces Title VI as well as other civil rights laws. http://www.justice.gov/crt/about/cor/coord/titlevi.php The Emergency Medical Treatment And Labor Act EMTALA requires most hospitals to provide an examination and needed stabilizing treatment, without consideration of insurance coverage or ability to pay, when a patient presents to an emergency room for attention to an emergency medical condition. http://www.cms.gov/EMTALA The Disadvantaged Minority Health Improvement Act Of 1994 Amends the Public Health Service Act to revise the duties of the Office of Minority Health. Provides for the establishment of the Advisory Committee on Minority Health to advise the Secretary of Health and Human Services concerning minority health. Requires each of the following agencies to establish its own Office of Minority Health: (1) Centers for Disease Control and Prevention; (2) Agency for Health Care Policy and Research; (3) Health Resources and Services Administration; (4) Substance Abuse and Mental Health Services Administration; and (5) National Institutes of Health (NIH). Reserves 0.5 percent of an agencys appropriation for such Office. http://thomas.loc.gov/cgi-bin/bdquery/z?d103:SN01569:@@@D&summ2=m& Health and Human Services Office of Civil rights As the Departments civil rights and health privacy rights law enforcement agency, OCR investigates complaints, enforces rights, and promulgates regulations, develops policy and provides technical assistance and public education to ensure understanding of and compliance with non-discrimination and health information privacy laws. http://www.hhs.gov/ocr/office/index.html Joint Commission Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals This monograph was developed by The Joint Commission to inspire hospitals to integrate concepts from the communication, cultural competence, and patient- and family-centered care fields into their organizations. The Roadmap for Hospitals provides recommendations to help hospitals address unique patient needs, meet the new Patient-Centered Communication standards, and comply with existing Joint Commission requirements. http://www.jointcommission.org/Advancing_Effective_Communication

QR Code*

* Scan the QR code with your mobile phone camera and favorite QR indentifying application to directly access these resources. QR readers are typically available to consumers at no charge.

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About the Author

Sahar Andrade, MB.BCh is a Diversity and Culture Competence Speaker/Consultant, as well as an international marketing expert certified as both an E-marketer and Social Media Strategist. Having lived, studied, and worked in 3 continents, Sahar speaks five languages and offers real world business experience with a straight-talk, hands-on approach to solving problems regarding cultural competence, diversity and their effect on global marketing and sales. As a recognized cultural communications consultant, Sahar has appeared multiple times on nationally syndicated radio such as 1100 AM KFNX news radio, as well as blog talk radio programs. She has been featured in articles appearing in Diversity and Bar, Medical Office Today, and multiple parental magazines. She also authors a column on Technorati Diversity Caf and is a featured columnist at the Global Diversity Factor. Sahar is a board member for the Los Angeles Chapter of the National Association of African Americans in HR. She holds a Bachelor of Medicine and a Bachelor of Surgery, minor in Psychiatry from Cairo University and has successfully completed a Mastery of Human Resources Studies Certificate Program. Sahar is the founder of Sahar Consulting, LLC.

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Also from The Beryl Institute

2011 September/October 2010

The Impact of Nurse Education and Ambient Noise Generators in Reducing Noise and Improving Patient Satisfaction in a Critical Care Unit
This report is based on research conducted at THE HEART HOSPITAL Baylor Plano in Plano, Texas. It was supported in part by The Beryl Institutes Patient Experience Grant Program.

Four Cornerstones of an Exceptional Patient Experience

A focus on the patient experience has forced new conversations to the forefront of hospital operations. The current requirements to publicly report HCAHPS scores ties the amount of reimbursement directly to levels of service performance. This paper highlights the results of two new surveys that illuminate the importance of the patient experience and describes the components of a successful service culture. Characteristics of top performers are detailed followed by case studies that illustrate service excellence. October 2010

The State of the Patient Experience in American Hospitals

Research conducted by The Beryl Institute shows that while patient experience is a top priority for hospital executives, it is still largely undefined. This landmark study of more than 790 hospital executives from all 50 states and DC examines the state of the patient experience in the nations hospitals and identified the greatest roadblocks to implementing change.

Insights into the Patient Experience Research Brief

In spring of 2010, The Beryl Institute surveyed its

The Revenue Cycle: An Essential Component in Improving Patient Experience

In considering the patient experience truly spans the entire continuum, before, during and after the clinical encounter, those looking to make improvements in patient experience can no longer restrict their line of sight. This paper considers the impact and outcomes resulting from the patients experience with a healthcare systems revenue cycle. The ideas shared are not definite answers, but rather ideas to encourage the necessary discussions organizations interested in improving the patient experience must have as they prioritize budgets, determine areas of investment and make critical choices that affect the lives of the patients, families and communities.

members to learn what patient experience efforts they had implemented within their organizations. The result gave important insights into the priorities of and challenges facing organizations working to tackle this critical issue. To see the latest data on challenges and opportunities in addressing the patient experience download this brief. July/August 2010

Zeroing in on the Patient Experience: Views and Voices from the Frontlines
Executives from The Beryl Institute hosted three patient experience leaders in a roundtable discussion on improving the patient experience. These patient experience champions come from varied backgrounds, but they bear one strong similarity a passionate commitment to creating exceptional experiences for patients, patient families and friends. In this paper they share the opportunities and challenges as they commit to improving how patients connect with their organizations.

Enhancing the Patient Experience Through the Use of Interactive Technology

Healthcare organizations are now looking to new modes of engaging patients and ensuring their stays, as well as their connection to the entire continuum of care, are unparalleled, positive experiences. One significant trend in providing exceptional patient experiences is the use of interactive technology. This paper highlights the benefits of using interactive technology and provides six case studies that quantify significant patient satisfaction improvements and impact on HCAHPS scores.

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February 2010

Perspectives on a Patient-Centered Environment

The Beryl Institute partnered with Sodexo, Inc. to release the white paper, Perspectives on a PatientCentered Environment. This healthcare industry focused paper explains how increasing employee engagement is the cornerstone for creating a patient-centered environment. When employees are engaged, they live the organizations mission, vision and purpose. They strive for the organization to succeed, and therefore, are more willing to do whatever it takes to meet customer expectations. The white paper includes three case studies that explore the connection between engaged employees and patient-centered care, the keys to creating an engaged workforce and drivers of employee satisfaction. June 2009

October 2008

Balancing Consumer and Physician Influence: Finding the Sweet Spot in Healthcare Marketing
This paper is authored by Al Swinney, senior vice president of marketing communications for Meridian Health. The paper explores the history of marketing to consumers, the relationship between physicians and hospitals, the physician as the patient influencer, and physician-tophysician marketing programs. Swinney explains how physician-to-physician marketing programs work and the immediate impact they can have on hospital volume. July 2008

Mystery Shopping the Patient Experience

This paper, written by Kristin Baird, The Baird Group and a faculty member of The Beryl Institute, outlines how mystery shopping goes beyond satisfaction surveys to discover why patients leave before they ever engage a health care provider. This paper explores the value of mystery shopping, how the shopping is done, and how healthcare organizations can turn the results into actionable improvement opportunities. November 2007

Customer Experience: A Generational Perspective

Michael Howe, former CEO of MinuteClinic, is an expert on retail healthcare. In this exciting new paper, Customer Experience: A Generational Perspective, he explores the social influences and characteristics of the four generations currently having the greatest impact on the healthcare system: Greatest Generation, Baby Boomers, Gen Xers, and Millennials. Howe discusses the challenges for healthcare providers in managing care for each generation. The paper includes a case study on MinuteClinic and concludes with customer service tips to improve the generational healthcare experience. March 2009

High Performing Organizations: Culture as a BottomLine Issue

This paper, written by faculty members Britt Berrett, now President of Texas Health Presbyterian Hospital Dallas, and Jason Wolf, Executive Director of The Beryl Institute, outlines the results of a ground-breaking study. It discusses Seven Truths about high performing organizations in case study format and provides actionable tips for hospital executives.

Character Counts: Integrating Civility into the Healthcare Culture

Award-winning publisher and author Chuck Lauer explores the need for hospitals to incorporate a civility initiative into their customer service programs. Lauer addresses the prevailing climate of rude behavior in society at-large and offers solutions to healthcare providers seeking to provide consumers with outstanding healthcare experiences, including five secrets for bringing civility to healthcare.

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August 2007

Moments of Truth: Hospital Switchboards a BottomLine Issue

Switchboard operators and other hospital-based call centers are the front-line of the customer acquisition process. Individual healthcare organizations are losing significant dollars by providing poor customer service at this initial touch point. Savvy healthcare leaders will close this service gap and transform their switchboards into customer focused and outcomes oriented front-line acquisition centers. This paper is the third in a series focused on the benefits of improving the customer acquisition process. May 2007

Its Not Just a Call, Its a Customer

Consumers are becoming more selective in making healthcare decisions and they are demanding convenience and accessibility from service providers. Data reveals that, contrary to popular belief, consumers are not willing to give providers a second chance if they are unable to make contact on the first try. This paper explores reasons why callers hang up before completing the call, the impact of lost revenue as a result of those abandoned attempts, and ways to decrease the number of callers who cannot get through. March 2007

Ready or Not, Customer Service is Coming to Healthcare

Consumers are gaining more control of healthcare spending. This will lead to a new culture where cost, quality and service are all part of the value equation. With pricing transparency and quality reporting standards, the true differentiator in the future will be service. Savvy healthcare leaders will transform their institutions to be consumer rather than patient focused, leading to new standards in care and service delivery.

Improving the patient experience

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