The Role and Relationship of Cultural Competence and Patient-Centeredness in Health Care Quality

Executive Summary

In recent years, patient-centeredness and cultural competence have been promoted as integral components in improving health care quality. Although these two approaches to health care delivery have grown out of separate traditions—each with its own focus—they have many similarities. This paper presents and compares models of patient-centeredness and cultural competence, and discusses their implications for improving health care quality at the level of interpersonal care and at the health-system level.

Patient-centeredness originated in the late 1960s as a way of characterizing how physicians should interact and communicate with patients on a more personal level. Core features include: understanding the patient as a unique person, exploring the patient's experience of illness, finding common ground regarding treatment through shared decision-making, and an emphasis on building the doctor–patient relationship. In essence, patient-centeredness involves perceiving and evaluating health care from the patient's perspective and then adapting care to meet the needs and expectations of patients.

While health care providers play an essential role in delivering patient-centered care, health care systems should also strive to be patient-centered. The Picker–Commonwealth Program for Patient-Centered Care began in 1987 to promote a patient-centered approach to hospital and health services, focusing on patients' needs and concerns. Some of the dimensions emphasized included: respect for patients' values, preferences, and expressed needs; coordination and integration of care; provision of information and education; and involvement of friends and family. In its 2001 report, Crossing the Quality Chasm, the Institute of Medicine (IOM) endorsed patient-centered care as one of six aims for health system improvement. Initiatives to promote patient-centered care include efforts to improve relationships between patients and providers, as well as efforts to make systems more responsive to patients' needs and preferences.

The issue of cultural competence in health care emerged later than did patient-centeredness. The term "cultural competence" did not begin to appear consistently in the medical literature until the early 1990s. The primary impetus for this movement in the last decade has been the demonstration of pervasive racial and ethnic disparities in health care, most notably publicized in the 2002 IOM report, Unequal Treatment. The report and its underlying research gave rise to an explosion of interest in culturally competent care.

Cultural competence must also be considered in the context of decades-old initiatives to eliminate the cultural and linguistic barriers between health care providers and patients, which can interfere with the effective delivery of health services. Sometimes described as "cross-cultural," "transcultural," "multicultural," or "culturally sensitive," these efforts were initially targeted at immigrant or refugee populations with limited English proficiency and exposure to Western cultural norms. Some efforts had the potential to emphasize culture-centered, rather than patient-centered care, which proved to be a drawback. That is, these efforts emphasized patients as members of ethnic or cultural groups, rather than as individuals with unique experiences and perspectives, possibly leading providers to stereotype and make inappropriate assumptions. With time, the cultural competence movement tempered this emphasis on specific cultural groups and expanded in scope to include all people of color, particularly those most affected by racial disparities in the quality of health care.

As in the patient-centeredness movement, pioneers of cultural competence recognized that disparities in health care quality may result not only from cultural and other barriers between patients and health care providers but also between entire communities and health care systems. Hence, there was a need not only to train culturally competent providers, but also to design culturally competent health care systems. To this end, efforts have been extended to make health care more accessible to people of color; to make the health care environment more inviting and culturally congruent with preferences of the patient population; to have providers and staff more ethnically similar to the community served; to offer interpreter services for those with limited English proficiency; and to collect data on quality of care stratified by race and ethnicity to track disparities in quality.

Both patient-centeredness and cultural competence aim to improve health care quality, but each emphasizes different aspects of quality. The primary goal of the patient-centeredness movement has been to provide individualized care and restore an emphasis on personal relationships. It aims to elevate quality for all patients. Alternatively, the primary aim of the cultural competence movement has been to increase health equity and reduce disparities by concentrating on people of color and other disadvantaged populations. Nevertheless, there is significant common ground between the two. To deliver individualized care, a provider must take into account the diversity of patients' perspectives, and so—to the extent that patient-centered care is delivered universally—care should become more equitable. Likewise, to the extent cultural competence enhances the ability of health care systems and providers to address individual patients' preferences and goals, care should also become more patient-centered.

At the core of both patient-centeredness and cultural competence is the emphasis on seeing the patient as a unique person. Proponents of cultural competence often make reference to the patient-centered approach when suggesting methods of interaction between patients and physicians. Thus, while not the exclusive focus of cultural competence, the general characteristics of patient-centered care (e.g., building rapport; exploring patient beliefs, values, and the meaning of illness; finding common ground) may be endorsed as aspects of cultural competence. Conversely, because cultural context is relevant to the care of all patients, not only to people of color, cultural competence has the capacity to enhance patient-centeredness and improve quality for all patients.

While patient-centeredness and cultural competence are highly congruent at the provider level, the same is not necessarily true at the level of health care systems. For example, culturally competent health systems may focus on recruitment of a diverse workforce, while patient-centered health systems may emphasize patients' ability to e-mail providers or have access to electronic medical records from home. Many commonalities remain however, such as the general belief that services should be aligned to meet patient needs and preferences; that health care should be available in communities, convenient to patients' homes; that educational materials should be tailored to patients' needs, health literacy, and preferred language; and that information on performance should be publicly available.

Because the cultural competence and patient-centered care movements both aim to improve health care quality in similar ways, it may seem reasonable to combine these efforts into a unified agenda. However, while many features are similar, there are important, disparate aspects of each (see Figure 1 on page 15). Patient-centered physicians and health care systems will benefit people of color and reduce disparities in health care quality, and culturally competent physicians and health care systems will benefit all patients and improve overall quality. As such, the authors recommend that patient-centeredness and cultural competence remain distinct but aligned efforts to both elevate and balance the quality of health care for all patients (Table ES-1).