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Interface between quality improvement, cultural competency, and the reduction of health care disparities – National Initiative for Children’s Healthcare Quality (NICHQ) Measures for Cultural Competency

The following is taken from

The cultural competency Change Package

A typical Change Package is a set of materials and ideas that guide and enable teams who are participating in a Collaborative to achieve breakthrough change in their settings. Change Packages generally have three elements:

  • a conceptual framework—in this case the Care Model for Child Health—that describes features of the ideal system for the topic;
  • a set of changes or strategies that have proven to be effective in achieving improvements (often called “change concepts”); and
  • a set of measures that enable Collaborative teams to track progress toward their goals.


Community Resources

Goal: Partnerships to meet the needs of families and children

Change Concepts

Potential Strategies

1. Create and sustain meaningful partnerships with key community leaders and representatives to enhance and inform communication between providers, staff, patients, and families and to iden-tify specific community strengths and needs.

• Assess and update information about community demographics, languages, and epidemiology.


• Encourage and retain participation of community members on organizational governing bodies and advisory committees.


• Establish and maintain forums for meeting with community leaders to identify key community concerns.


• Have community leaders serve as liaisons between providers/staff and community members.


• Meet with community leaders and organizations to improve access and promote preventive care.


• Encourage families to participate in community programs that are effective at improving health and mental health outcomes (e.g., physical activity programs).

2. Involve community in planning, implementing, and evaluating services and policies.

• Include community members in process for developing, implementing, and evaluating education and resource materials.


• Identify community representative(s) to engage in quality improvement and patient safety programs (e.g., preventive services).


• Organize focus groups, including community leaders, to aid in planning service changes including those related to the CLAS standards.


• Address identified barriers to community participation in planning, implementing, and evaluating provided services (e.g., childcare, funding, etc.).


• Assess and address community reported barriers and facilitators to care at all levels both quantitatively and qualitatively. 


• Establish and utilize relationships with diverse race/ethnic/language news sources to promote preventive screening and positive health behaviors.


Healthcare System and Organization


Goal: Create an environment and mechanisms that promote high quality care


Change Concepts

Potential Strategies


1. Assess organizational and individual under-standing of culturally and linguistically effec-tive care and implement appropriate strategies for making and sustaining improvements.

• Cultural competence is part of job descriptions.



• Use a standardized tool for annual organizational assessment of cultural competency (including signs, materials, trainings, staff diversity, etc).



• Collect, analyze, and report patient population data by race, ethnicity, and language.



• Analyze all quality and patient safety indicators by race, ethnicity, and language to identify areas of disparities in care.



• Integrate cultural competency related measures into internal audits, performance improvement, and error reduction programs. (e.g., use of interpreters).



• Use varied methods (e.g. online, self-paced, in-person training) to educate providers and staff about culturally competent care, and evaluate the training outcomes.



• Educate providers and staff about how to elicit and document families’ cultural beliefs and practices.



• Identify bi- and multi-lingual staff and train them to be interpreters.



• Train providers in the use of trained and untrained interpreters.



• Provide training in CLAS standards, Limited English Proficiency (LEP) guidelines, Title VI, and general culturally competent care strategies to all staff and providers.



• Include information about culturally proficient care in employee orientation programs.


2. Involve community in planning, implementing, and evaluating services and policies.

• Educate organizational leaders about why culturally competent care is essential to high quality care. • Adopt written policies and procedures that support culturally and linguistically competent care.


• Adopt written policies and procedures that support culturally and linguistically competent care.


• State organizational intent with regards to cultural competency in strategic plan and policy and mission statements.


• Have organizational leaders develop/review, revise, and recommit to organization’s mission in the area of culturally effective care; develop specific goals to support mission.


• Establish a budget line and a reporting system within the institution for all cultural competency related activities including interpreter services and staff/provider training.


• Integrate cultural competency into all discussions of patient care and operations at staff meetings, presentations, and other core activities.


• Business and service decisions should consider identified disparities and understanding of the population served.


• Remain transparent when dealing with any errors and barriers to quality care in areas where disparities have been identified.


• Implement a system (that includes dedicated staff time) to recruit, retain, and promote minority staff who are reflective of the patient population served.


• Designate staff responsible for overseeing implementation of activities to promote acceptance, understanding, and enthusiasm for all aspects of culturally proficient care.


• Provide grievance process information that is available in the preferred languages of the patient population served.


• Provide incentives to encourage improvement of quality of care for all patients.


• Integrate cultural competency related measures into patient satisfaction assessments.


• Include cultural competency related issue on new patient/intake forms. (e.g., use of complimentary and alternative medicine, traditional healers).


• Increase allotted visit time for patients requiring interpreters.

• Reflects by organizational setting the patient population served through artwork, color scheme, and multi-lingual signage.

3. Provide linguistically effective care at all points of contact.

• Provide and adequately fund interpreter services. • Implement a system to link bi- or multi-lingual staff with LEP patients. • Visibly and accessibly provide information about patients’ right to receive language assistance in multi-lingual signage throughout the system.


• Visibly and accessibly list local options for interpretation (e.g., telephone interpreters, in person interpreters, etc.).


• Identify cultural/linguistic barriers to care in order to help patients navigate the healthcare system.


• Identify pertinent demographic information that will assure referral settings are knowledgeable of specific patient needs (e.g., preferred language, need for interpreter).


• Use a“navigator” program for new immigrants.


Family and Self-Management Support

Goal: Support families to manage the health care of their children

Change Concepts

Potential Strategies

1. Determine and incorporate relevant cultural healing traditions and beliefs into patient care and communication.

• Elicit patient/family’s health beliefs and use of complementary and alternative medicine therapies during primary care visit.


• Perform assessments of patient/family self-management knowledge, supports, and barriers to good health.


• Use expertise from the community to educate providers and staff about cultural norms and values.



2. Prepare families to be engaged, empowered and educated so they are active partners in their child’s care.

• Provide translated/interpreted informed consent.


• Use a care and treatment plan that is agreed upon and includes input from patient/family.


• Assess parental satisfaction with self-management materials.


• Include family input on teams working to tailor self-management tools. 


• Provide all health materials and programs in a culturally and


linguistically appropriate manner.


• Review and adapt existing translated material (e.g., asthma


self-management plan) for use by communities served.


Decision Support

Goal: Promote clinical care that is consistent with scientific evidence and family preferences

Change Concepts

Potential Strategies

1. Embed evidence-based guidelines into daily practice and share information with families to encourage participation in care.

• Use, and tailor, as needed, evidence-based guidelines for all patient populations.


• Inform patients of the availability of guidelines pertinent to their care.

2. Provide clinicians access to reliable resources for learning about health beliefs and practices of cultural groups in the community.

• Gather population demographics, epidemiological statistics about disparities in health and health care, prevalent health beliefs and healing traditions for predominant cultures served (e.g., breast feeding, parenting, immunizations.)


Delivery System Design

Goal: Assure the delivery of effective, efficient, patient-centered care

Change Concepts

Potential Strategies

1. Provide consumers with effective and respectful care compatible with their cultural beliefs and practices and in their preferred language.

• Use standardized questions or tools such as language cards for assessing preferred language.


• Use a standardized instrument to assess health literacy.


• Conduct informational sessions for staff to raise awareness of local health disparities as well as demographic and language trends.

2. Create an effective and efficient system to define roles and responsibilities regarding culturally effective care and distribute tasks among members.

• Incorporate language/interpreter needs at time of scheduling and when designing visits. 


• Create and tailor group visits to address needs and preferences of communities, patients, and families served.


Clinical Information System

Goal: Organize data to facilitate population-based care

Change Concepts

Potential Strategies

1. Create a standardized system to collect all relevant patient demographic data.

• Incorporate demographic data into any existing Electronic Medical Record (EMR) or data system.


• Ensure that data fields for race/ethnicity and language (at a minimum) are present in registration systems.


• Train staff to use, collect, and input data into the organization’s information system in a consistent, standardized way.


• Use data to inform population-based and individual care.


• Use data to monitor performance of practice team and health system.

2. Use reports and data by relevant groups to pro- vide feedback for staff, providers, and families.

• Link collected demographic and epidemiologic data with patient satisfaction surveys, provider feedback reports, and filed grievances and complaints.


• Link demographic data with quality and patient safety measures, QI reports, and clinical outcomes.


• Collect consistent information across sites and make universally available in the interest of comparison and care improvement.


One of the key questions we ask in improvement work is, “How will we know that the changes being made are making things better?”

Tracking progress on specific measures related to the changes is one way to answer this question.How will healthcare delivery organizations know if the changes they might make will lead to more culturally competent care? With input from experts in the field, as well as academic and clinical leaders in health care and cultural competency, we developed measures that delivery organizations can use. These measures are grouped into “Core Measures,” those that are essential to meeting the goal of cultural competency, and “Additional Measures,” those that are important but somewhat less significant. The latter may be considered optional, to be chosen by providers who wish to use them.

 There are three types of Core Measures.

  • Outcome measures show whether or not organizations are achieving their desired results. They are the ultimate voice of the patient. They report on the result of the change concepts and strategies in practice as they affect the patient’s experience and outcomes of care. This includes if their health is improved and if their subjective experience of receiving care is positive. Outcome measures reveal the effects of key changes.

  • Process measures let us know if the system is performing as planned. They are the voice of the system. They describe the process of care and the changes in service delivery; documentation of these processes can come from patients telling whether or not they receive care in their preferred language, or from clinical or administrative records, stating whether the need for an interpreter was documented.

  • Structural measures indicate whether the pre-conditions that are established are more likely to result in effective processes and better outcomes for children and families. Structural measures include the level of training of staff and the staff ’s demographic characteristics.

  • Additional Measures include balancing measures. These measures tell us what is happening to the system as we make improvements in our outcome and process measures. They provide a perspective on the unintended side effects of change throughout the system: Are you improving some part of the system at the expense of others, such as patient satisfaction or waiting times? Other additional measures assess processes and outcomes, but are not as central to the aim of achieving cultural competency and reducing disparities. …

We have highlighted in this section three core measures … as a starting point:

These are:

  • Disparities: an Outcome measure to determine the magnitude of differences among racial/ethnic groups in key clinical outcomes. For example, do immunization rates among all children or rates of emergency department visits for kids with asthma differ among African-American, White, and Latino children?

  • Language: a Process measure to determine the percentage of patients receiving care in their preferred language.

  • Identification of race, ethnicity, and language preference: a Process measure to determine to what extent practices are identifying and tracking this information. Ideally, families should be asked to self-identify by answering standardized questions about race, ethnicity,and the preferred language for their health care encounters. It is preferable for providers to use the same categories used by the U.S. Census for assessing these characteristics. Providers may wish to begin by first using these three core measures to assess their progress toward achieving the goal of reducing disparities in children’s health care, and then slowly add other recommended measures over time.