Cultural Competence-Are We There Yet?

As I walked down the hallway of an acute care facility in an overwhelmingly Latino community last month, I overheard a health care provider abruptly retort to a non-English- speaking patient: "You people should learn to speak English”. My heart sank as I bemoaned this incident as an example of the painfully slow progress our United States (US) health care industry is making toward cultural competence. It made me reflect over the past decade, as ethnic, racial and linguistic diversification of the US progresses at giant paces, and ask: Are we there yet? Are we making adequate progress toward cultural and linguistic competence? How can we tell? Answers to these questions require a common definition of cultural and linguistic competence as well as a framework that will allow us to measure our progress.

Cultural and linguistic 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.1 Competence implies having the capacity to function effectively as an individual and an organization within the context presented by consumers and their communities.2 Cross and colleagues offer a framework that can serve as a helpful tool for the assessment of cultural and linguistic competence.2

According to Cross and colleagues, cultural and linguistic competence exists on the following six-point continuum: 1) cultural destructiveness, 2) cultural incapacity, 3) cultural blindness, 4) cultural precompetence, 5) basic cultural competence, and 6) cultural proficiency. The lowest extreme of cultural incompetence is cultural destructiveness and, fortunately there are few examples of this in today’s US health care industry.

Cultural incapacity is characterized by health care providers who routinely perpetuate societal biases, beliefs in racial inferiority and paternalism. They tend to discriminate in their hiring practices, and send messages that ethnically or racial diverse individuals are not valued or welcomed, and usually have lower expectations for their clients. Unfortunately, examples of this are still visible in the US health care industry.

Cultural blindness is characterized by health care providers who assert that race and culture make no difference in how services are provided. This results in the application a dominant cultural approach to all clients, ignoring strengths and uniquenesses of ethnically and racially diverse people. Thus, leading to forced assimilation with potential placement of blame on individuals rather than society for existing problems.

More to the positive end of the continuum is cultural precompetence, which is characterized by health care providers who make sincere efforts to become more multicultural but have had difficulty in making progress. These health care providers realize they have problems in serving ethnically and racially diverse groups and have discovered this fact through ineffectual efforts at serving a single ethnic population. They tend to lack a realistic picture of all that is involved in becoming culturally competent and often succumb to either a false sense of accomplishment or a particularly difficult failure. They fall prey to tokenism and put unrealistic hopes in the hiring of one or two professions from diverse ethnic and racial groups, whose cultural competence they tend to overestimate.

Basic cultural competence is characterized by health care providers who work to hire unbiased employees, seek advice and consultation from the minority community, and actively decide what they are and are not capable of providing minority clients.2 The most positive point on the continuum is cultural proficiency, which is characterized by health care providers who, in addition to basic cultural competence, advocate more broadly for multiculturalism within the general health care system and are engaged in original research on how to better serve culturally different clients and its dissemination.

Given Cross and colleagues’ framework, where does the US health care industry stand? Is the US health care industry making significant progress toward the goal of cultural proficiency to address the cultural and linguistic barriers to health care delivery and increase access to health care for limited ethnically and racially diverse people? There is ample evidence that indicates that the US health care industry maybe at the cultural pre-competence point on Cross and colleagues’ (1989) continuum of cultural and linguistic competence.2 The greatest demonstration of this is the development and implementation of the National Standards on Culturally and Linguistically Appropriate Services (CLAS).1

The CLAS standards are a collective set of culturally and linguistically appropriate services mandates, guidelines, and recommendations intended to inform, guide, and facilitate required and recommended practices related to culturally and linguistically appropriate health services.1 The CLAS standards are primarily directed at health care organizations. However, individual health care providers are also encouraged to use the standards to make their practices more culturally and linguistically accessible.

The fourteen standards are organized by themes: Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational Supports for Cultural Competence (Standards 8-14). Within this framework, there are three types of stringency: mandates, guidelines, and recommendations. CLAS mandates are current Federal requirements for all recipients of Federal funds, Standards 4 - 7. The CLAS mandates, Standards 4 -7, are the priority for health care agencies because these mandates are required for receipt of federal funds.1

Standard 4 states that health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. Standard 5 states that health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. Standard 6 states that health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). Standard 7 states that health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. Implementation and enforcement of the CLAS mandates has been difficult for the US health care industry, providing evidence that cultural precompetence prevails. This difficulty is being addressed by the Joint Commission on Accreditation of Healthcare Organizations.3

The JCAHO has included cultural competence in its standards that support effective communication, cultural competence, and patient-centered care. These standards formally and publically acknowledge the need to actively develop and implement measures that will support cultural competence. The JCAHO, with funding from the Commonwealth Fund, is also developing proposed accreditation requirements for hospitals to advance effective communication, cultural competence, and patient-centered care through a special project.3

This 18-month project will increase national attention to cultural competence, highlight its intersection with patient-centered care, and improve the safety and quality of care for all patients.3 At the earliest, any implementation of the proposed requirements would occur in January 2011. The project explores how diversity, culture, language, and health literacy issues can be better incorporated into current JCAHO standards or drafted into new requirements. The proposed requirements to advance effective communication, cultural competence, and patient-centered care build upon previous studies and projects and evidence from the current literature. A multidisciplinary expert panel, representing a broad range of stakeholders, is providing guidance regarding the principles, measures, structures, and processes that serve as the foundation for the proposed requirements to advance effective communication, cultural competence, and patient-centered care.

The CLAS Standards and the ongoing work of the JCAHO clearly indicate that the US health care industry is at the cultural pre-competence point on Cross and colleagues’ continuum of cultural and linguistic competence. This means that the US health care industry is still actively seeking ways to capture or measure cultural and linguistic competence before it can resolve the challenges to enforce the CLAS Standards. This bears great promise for the progression toward cultural and linguistic proficiency in the US. However, this progress is contingent upon active engagement by health care providers everywhere to ensure that this progress keeps its forward stance. This is critical for the rapidly growing diverse population of the US, a population that is counting on all of us to victoriously proclaim: "We have arrived at the cultural proficiency point of Cross and colleagues’ continuum of cultural and linguistic competence.”2


  1. US Office of Minority Health CLAS Standards. (2001). Accessed July 15, 2009 at: http://www.omhrc.gov.
  2. Cross, T.L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. (1989). Towards a Culturally Competent System of Care. Washington, DC: Georgetown University Child Development Center.
  3. Joint Commission on Accreditation of Health Care Organizations Standards. (2009). Accessed June 4, 2009 at: http://www.jointcommission.org


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