A Framework for Cultural Competency: Measurement and Accountability

By Robyn Y. Nishimi, Ph.D., Chief Operating Officer of the National Quality Forum

At The Commonwealth Fund's April 2005 Cultural Competency Roundtable, I called for a framework for culturally competent heath care to be available to the National Quality Forum (NQF) by January 1, 2007. We are far enough along in our understanding of the research base to identify key concepts that describe the essential elements of cultural competency. While there is certainly more research to be done, I believe that it's time to move the agenda forward—and that the best way to make significant strides in providing culturally competent care is through measurement and public reporting of performance.

NQF is a consensus standards-setting body that focuses on standardized measurement and reporting as key drivers of improvement in U.S. health care. Our processes comport with federal law that encourages development of standards in the private sector, including those to standardize health care quality performance measurement: If the government is going to require measurement of performance in a certain area, it must use consensus standards from the private sector or explicitly state why it has chosen to do otherwise. NQF partners with its public and private sector members to endorse and disseminate such consensus standards, and to date we have endorsed 27 serious reportable events, 30 practices to improve patient safety, and approximately 200 performance measures to gauge hospital, nursing home, home health, and physician-level ambulatory care. Today, consumers can find comparative quality information based on NQF-endorsed performance measures for hospitals, nursing homes, and home health care providers on the federal government's Medicare Web site. Minnesota and Connecticut state governments issue an annual report on patient safety errors for hospitals in their states using the NQF list of serious reportable events. And private purchasers have required that providers who serve their employees measure and report data based on NQF-endorsed consensus standards.

To bring the cultural competency movement to this next level, we need consensus on a framework for measuring and reporting the quality of culturally competent care. Efforts to define and measure culturally competent care are already in progress, catalyzed by the Office of Minority Health's recent publication of Culturally and Linguistically Appropriate Services (CLAS) standards for health care organizations. The National Committee for Quality Assurance now has a recognition program for health plans that demonstrate innovative approaches in meeting the CLAS standards. Earlier this year, the Joint Commission on Accreditation of Healthcare Organizations introduced two standards requiring hospitals to indicate patients' native language and communication needs in their medical records and to document the language services provided during medical encounters. And the Centers for Medicare and Medicaid Services has several cultural competency quality improvement initiatives, including an online training program for family practitioners. Still, there needs to be a coordinated effort to bring together these disparate activities.

A national framework would enable patients, physician practices, hospitals, nursing homes, health plans, and other health care organizations to work toward a shared understanding and common goals for providing culturally competent care. Once a framework is in place, we can begin to describe the preferred or best practices, develop specific measures, and report performance data.

Language services provide a useful example of how this might work. We know that family or staff members are often used for ad-hoc translations services. In other cases, translation is provided by on-site trained medical interpreters or by third-party telephone services. A consensus-derived framework might find that the preferred translation practices—based on evidence of their safety and effectiveness—are, first, to have a trained interpreter on site and, second, to use a call-in service. It also might find that relying on family members or untrained staff is not a recommended practice. It would then be possible to measure the percent of patients receiving appropriate translation services. More sophisticated measures could be developed over time, for example adjusting for factors such as uncommon languages that providers could not reasonably be expected to cover.

Some might argue that language services are one of the more easily described elements of culturally competent care. How can we assess performance for less tangible aspects, such as whether health care providers show respect for their patients and take their cultural or religious preferences into account? We know that the quality of patient–provider relationships is important—it affects patients' adherence to treatment regimens and their satisfaction with care. Measuring patient experience of care through surveys such as the Hospital Consumer Assessment of Healthcare Providers and Systems (which NQF has endorsed) and then stratifying results by race and ethnicity would be a first step to address these complex areas.

Beyond these examples, however, are myriad ill-defined (or at least non-standardized) areas as to what constitutes high-quality, culturally competent care. Certainly, more research and trials are needed to fill in the picture. But a framework would provide focus and clarity—spotlighting promising practices and pinpointing areas that need further work.

I'm not looking for perfect care; our health care system already carries heavy burdens. But we can do vastly better in providing care that is equitable—and we can begin by holding our health care system accountable by launching a process to reach consensus on a framework for culturally competent care.

Robyn Y. Nishimi is the chief operating officer of the National Quality Forum, a private, nonprofit, membership organization whose mission is to improve health care through measurement and public accountability.

The views presented in this commentary are those of the author and should not be attributed to The Commonwealth Fund or its directors, officers, or staff.