Patient Experience Body of Knowledge
Domain Content Development Process
Cultural Competence and Diversity Team
Sharon A. Brodie
George Handzo
Cynthia Hogan
Colleen Miles
Director Service Excellence, Duke Raleigh Hospital
President, Handzo Consulting
Manager, Patient Experience, Tenet Healthcare
Patient Representative, Carroll Hospital Center
Patient Experience Body of Knowledge – Module Development | The Beryl Institute ©2012
Improving the Patient Experience
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Module Development Template
DOMAIN NAME: Cultural Competency and Diversity
DOMAIN OBJECTIVE: Understanding the impact that diversity and difference plays in the design and delivery of effective
patient experience efforts.
DOMAIN LEARNING OBJECTIVES (3-5):
1. Cultural Self Awareness
2. Regulatory
3. Diverse Populations
4. Key Terminology
DOMAIN OUTLINE
5. Section I
Cultural Self Awareness
Objective: Understand how cultural self awareness is a necessary prerequisite to
delivering culturally competent care.
Outline of Concepts
A. How do you identify yourself?
• Culture
• Ethnicity/Race
• Gender
• Social role
Key learning point(s)/take away ; Understand one’s cultural/ethnic heritage.
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B. Types of values and beliefs
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Beliefs and values about illness, health, medical treatment
Beliefs and values about gender roles
Religious beliefs and values
Key learning point(s)/take away: Be able to identify the important values and
beliefs in one’s life.
C. Basic assessment components
 Sense of self and space
 Communication and language
 Dress and appearance
 Food and eating habits
 Time and time consciousness
 Relationships
 Views and norms
 Beliefs and attitudes
 Mental process and learning
 Work habits and practices
Key learning point(s)/take away: Be able to do a personal cultural assessment
D. Relationship to other groups
 Ethnic/Racial groups
 Religious groups
 Disabled groups
 Social groups
 Political groups
Key learning point(s)/take away: Understand how one relates to other groups in
society and what one’s preconceptions are about those groups.
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E. Relationship of generalities and stereotypes
 Preconceptions and stereotypes
 Use of generalities.
Key learning point(s)/take away: Be able to discuss the differences between
generalities and stereotypes.
Section II Name: Regulatory and statutory oversight for hospitals and critical access hospitals of patient rights relative to cultural
competency and diversity.
Objective: Promote multicultural inclusion through awareness, understanding, and
appreciation of equity and diversity.
Understand the rights of individuals from diverse cultures and backgrounds
Outline of Concept:
A. Joint Commission (Regulatory)
 “Policies and procedures that systemically support efforts to meet the needs of diverse patients can help
elevate the priority of these issues within the organization, drive efforts, and draw staff support.
Developing practices that address the challenges of certain populations contributes to providing safe,
quality care and decreasing health disparities” (Joint Commission).
 “The Joint Commission views effective communication, cultural competence, and patient- and familycentered care as important components of safe, quality care” (Joint Commission, 2010, p. 3).
 Relevant Joint Commission standards and elements of performance are included in the Roadmap for
Hospitals published by the Joint Commission 2010 and in The Joint Commission LGBT Field Guide
published by the Joint Commission in 2010.
 As of July 1, 2011, The Joint Commission requires that organizations accredited under the hospital and
critical access hospital programs prohibit discrimination based on many factors, including sexual
orientation and gender identity or expression. (Joint Commission, 2011).
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B. CMS (Regulatory)
 The Centers for Medicare & Medicaid Services (CMS) updated their Conditions of Participation (CoPs) in
January 2011 for hospitals and critical access hospitals (CAHs) to require equal visitation for patients.
These COPs state that “A hospital must have written policies and procedures regarding the visitation rights
of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that
the hospital may need to place on such rights and the reasons for the clinical restriction or limitation.”
(Center for Medicare and Medicaid Services)
C. Americans With Disabilities Act (ADA) (Statutory)
(ADA Home Page)
D. Title VI Of The 1964 Civil Rights Act 42 U.S.C §§ 2000d - 2000d-7 (Title VI) (Statutory)
Title 42 - The Public Health and Welfare Subchapter V – Federally Assisted Programs
Bibliography
ADA Home Page. (n.d.). Retrieved from www.ada.gov: http://www.ada.gov/
Center for Medicare and Medicaid Services. (n.d.). In Code of Federal Regulations for Hospitals (p. 42 C.F.R § 482.13(h) ).
Joint Commission. (2010). Advancing Effective Communication, Cultural Competence, and Patient and Family-Centered Care. IL:
Oakbrook Terrace.
Joint Commission. (2011). Comprehensive Accreditation Manual for Hospitals -- Update.
Joint Commission. (n.d.). One Size Does not Fit All: Meeting the Health Care Needs of Diverse Populations. Retrieved from
www.jointcommission.org/PatientSafety/HLC
Justice Department. (n.d.). Titlevistat. Retrieved from www.justice.gov: http://www.justice.gov/crt/about/cor/coord/titlevistat.php
Section III Name: Diverse Populations
Objective: Understand how to accommodate diverse patient populations;
Explain how accommodating diverse patient populations begins with staff awareness
Outline of Concept:
A. Cultural Competence to improve patient safety
 Direct communication can influence -
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
o Language proficiency barriers
o Hearing or vision impairment
o Literacy and health literacy
o Cognitive limitations; physical disabilities
o Sexual orientation and gender identity
o Generational
Lack of sensitivity to a cultural belief may be a risk for poor patient outcomes
Key learning point(s)/take away: To understand why diversity and cultural competency are important components of
quality and safe patient care
B. Understand the needs of patient populations
 self assessment using data to identify needs
o (community & hospital) for planning, designing and implementing practices to address their needs
 Demographic data (age, culture, diet, language, race, religion, etc)
 Patient satisfaction
 Risk & error reports
Key learning point(s)/take away: Understanding an organization’s unique
patient population to decrease its health disparities, and improve quality and
patient safety.
C. Implementing practices to help address needs
 patient centered care communication models (AIDET, RELATE, Language of Caring, Teach Back, etc)
 Open visitation hours
 Signage
 (CLAS) interpreter services & language services
 physical space
 Patient training and education to include/promote self care & patient engagement (videos, written, audio,
etc)
Key learning point(s)/take away: Understanding that effective communication
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and patient centered care models help to address safe, quality patient care .
D. Monitoring the data
 Patient satisfaction surveys
 Chaplaincy records
 Dietary requests
 Interpreter services
 Focus groups and patient interviews
Key learning point(s)/take away: To understand how to monitor and use data to
make improvements to meet the needs of diverse patient populations
E. Hiring, training and supporting a diverse work force
 Mission, Vision, Values support diversity and cultural competency
 Executives demonstrate on-going commitment and support
 Hiring practices to promote a diverse work force
(recruiting for specific skill sets)
 Training and Support
 Effective communication models for staff
 Cultural competence training for staff at orientation, on-going, annually
 Types of training (listening, story telling, collaboration)
 Competency demonstration
 Who conducts the training (cultural coach?)
Key learning point(s)/take away: Understanding that accommodating diverse
patient populations needs to improve patient quality and safety starts with staff
awareness
Bibliography: The Joint Commission. One Size Does Not Fit All: Meeting the HealthCare Needs of Diverse Populations AmyWilsonStronks, Karen K. Lee, Christina L. Cordero, April L. Kopp, and Erica Galvez.
<http://www.jointcommission.org/assets/1/6/HLCOneSizeFinal.pdf>
Section IV Name: Terminology
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Objective: Identify key definitions and terms associated with cultural diversity
Outline of Concept: Terminology
Acculturation - the process of adopting the cultural traits or social patterns of a group other than one’s own. In regard to immigrant
groups, acculturation is the process of incorporating values, beliefs and behaviors from the dominant culture into the immigrants’
cultural worldview.
Assimilation - the process of taking on the cultural traits and characteristics of another distinct group; absorption of a new or different
culture into the main cultural body; to make like; to cause to resemble.
Bicultural - the ability to understand and function effectively in two cultural environments. An individual who is bicultural is not
necessarily culturally competent.
Bilingual - the ability to effectively speak two languages.
CLAS standards - the collective set of culturally and linguistically appropriate services (CLAS) mandates, guidelines, and
recommendations issued by the United States Department of Health and Human Services Office of Minority Health intended to
inform, guide, and facilitate required and recommended practices related to culturally and linguistically appropriate health services
Comparability of access or benefits - meaningfully equal access and benefits across all populations served, including any
adaptations necessary to achieve equality.
Competence - 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.
Cultural Awareness - Developing sensitivity and understanding of another ethnic group. This usually requires internal changes in
attitudes, awareness and sensitivity to behaviors. Awareness and sensitivity also refer to qualities of openness and flexibility that
people develop in relation to others. Cultural awareness must be supplemented with cultural knowledge.
Cultural blindness - Differences are ignored and one proceeds as though differences do not exist. ("There's no need to worry about a
person's culture; if you're sensitive, you'll do OK.")
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Cultural broker or Culturally-informed consultant - a person serving in a non-clinical or non-professional capacity who is
recognized by the client’s cultural or linguistic community as one who has knowledge of a particular culture or language and its
definition of health, mental health, and family dysfunction and who is used by service providers and organizations to assist in
providing culturally and linguistically-appropriate service. The term should not be confused with a professional consultation between
a mainstream provider and a culturally-specific provider. There are no established criteria for certifying when an individual is
culturally informed, but the organization may establish a test to determine a consultant’s usefulness in facilitating positive client
outcomes. An organization that uses cultural consultants to facilitate face-to-face client encounters may use feedback from clients and
families.
Cultural and linguistic competence in health - 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.
Cultural imposition - belief that everyone should conform to the majority. ("We know what's best for you. If you don't like it you
can go elsewhere.")
Culturally and linguistically appropriate services - health care services that are respectful of and responsive to cultural and
linguistic needs
Culturally competent provider means a service professional who understands, and can utilize to the client’s benefit, the client’s
culture either because he or she is of the same cultural or ethnic group or because the provider has developed the knowledge and skills
through training and personal growth to provide high-quality service to diverse clients. The term can be used in a practical sense to
indicate success in achieving positive outcomes for clients. At this time, DHS has not adopted criteria to certify or measure cultural
competence.
Culturally responsive teaching - cultures responsive teaching is a pedagogy that recognizes the importance of including student’s
cultural references in all aspects of learning.
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Culturally-specific intervention - interventions or treatments that are common to or are especially effective with a specific
population or services provided by practitioners who are characteristically found within a particular population. Expectations of high
service quality remain.
Culture - the integrated pattern of socially transmitted human behavior that includes thoughts, communication, actions, customs,
beliefs, values, and institutions, and all other products of human work or thought, characteristic of a particular community or
population. Culture is a set of guidelines, both explicit and implicit, which individuals inherit as members of a particular society, and
which tells them how to view the world, how to experience it emotionally, and how to behave in relation to other people, to
supernatural forces and gods, and to the natural environment.
Cultural is the most broad and overarching fabric of the social environment. It may include racial, ethnic, religious, or social
communities or populations. Race is separate from culture. Culture is more about behavior than biology. Emphasizing culture when
discussing how human services workers develop cultural competency—and removing race from that discussion—helps to focus on the
behaviors, attitudes, and practices needed in order to effectively serve diverse cultural communities.
Culture-bound behaviors or culture-bound syndrome - culture-specific behaviors, conditions, and diseases that affect a person’s
health and well-being.
Discrimination - differential treatment of an individual due to minority status, both actual and perceived. ("We just aren't equipped to
serve people like that.")
Disparity - inequality in outcome or condition between cultural groups or differences in outcomes or conditions between cultural
groups that are not predictable based on the number of group members present in the general population.
Diverse populations - distinct groups including, but not limited to, racial and ethnic minorities, persons of color, American Indians,
gay, lesbian, bisexual, and transgender cultures, deaf culture, disabilities culture, economic class cultures, and immigrants.
Dynamics of Difference - the interpersonal interactions that occur in a cross-cultural encounter. When one culture interacts with the
population of another, both may misjudge the other’s actions based on learned expectations. Each party brings to the relationship
unique histories with the other group and the influence of the current political relationship between the two groups. Both will bring
culturally-prescribed patterns of communication, etiquette, and problem solving. Both may bring stereotypes or underlying feeling
about serving—or being served by—someone who is “different.” Such tension is part of the cross-cultural encounter. Both
professionals and clients should be vigilant against misinterpretation and misjudgment.
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Ethnic - designating basic groups or divisions of human beings as distinguished by customs, a common language, a common history,
a common religion, or other such characteristics
Ethnicity - ethnic quality or affiliation
Ethnocentrism - Inability to accept another culture's world view. ("My way is best.")
Ethnographic interview - a meeting with a person of another culture in order to begin understanding his or her worldview, beliefs
and life situation. It is a way to examine the patterned interactions and significant symbols of specific cultural groups to identify
cultural rules that direct behaviors and the meaning people ascribe to such behaviors. Ethnographic interviewing helps a person
understand another culture while avoiding stereotyping. An ethnographic interviewer is in control of the structure of the event, while
the interviewee is in control of the cultural content of the event. The interviewer is the learner and the interviewee is the teacher.
Interpreter - an individual trained and/or certified in facilitating oral, written, or manual communication between two or more people
of different languages. For the purpose of these Guidelines, a qualified interpreter possesses in-depth knowledge, not only of the
language, but also of cultural values, beliefs, and verbal and non-verbal expressions. A technically proficient interpreter who is lacking
specific cultural knowledge can work in conjunction with a culturally informed consultant (also known as a cultural broker).
Limited English proficiency (LEP) or persons with LEP - individuals who cannot speak, read, write or understand the English
language at a level that permits them to interact effectively with health care providers and social service agencies. (Note: This may not
be easy to identify. Some people may know enough English to manage basic life skills but may not speak, read, or comprehend
English well enough to understand in a meaningful way some of the more complicated concepts they may encounter in the health and
human services systems.)
Linguistic competence - the capacity of an organization and its personnel to communicate effectively, and convey information in a
manner that is easily understood by diverse audiences including person of limited English proficiency, those who have low literacy
skills or are not literate, and individuals with disabilities. The organization must have policy, structures, practices, procedures and
dedicated resources to support this capacity.
Meaningful access - the ability to use services and benefits comparable to those enjoyed by members of the mainstream cultures. It is
achieved by eliminating communication barriers and ensuring that the client or potential client can communicate effectively.
Preferred language - the self-identified language, which the client prefers to use in a service or clinical encounter.
Patient Experience Body of Knowledge – Module Development | The Beryl Institute ©2012
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Race - any of the different varieties of human beings as distinguished by physical characteristics; one among the group of populations
constituting humanity, where differences are biological in nature and are transmitted genetically. The term is inaccurate when applied
to national, religious, geographic, linguistic, or cultural groups.
Stereotyping - Generalizing about a person while ignoring the presence of individual differences. ("She's like that because she's
Asian; all Asians are nonverbal.")
Bibliography KU Work Group for Community Health and Development. (2010). Part H. Cultural Competence, Spirituality, and the Arts and
Community Building (Chapters 27 - 29). Retrieved January 2, 2010, from the World Wide Web:
http://ctb.ku.edu/en/tablecontents/section_1045.htm
Minnesota Department of Human Services
National Standards for Culturally and Linguistically Appropriate Services in Health Care Final Report, OMH, 2001
U.S. Department of Health and Human Services Office of Minority Health, and the Community Tool Box, a public service of the
University of Kansas. They are reprinted here with their permission.
OUTSIDE RESOURCES/SUPPORTING MATERIALS TO CONSIDER:
(Provide a list of all suggested materials)
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http://crculturevision.com first comprehensive, user-friendy databses that gives healthcare professionals access to culturally
competent patient care.
http://www.divestiyrx.org/activities/clstalk-listserv CLAS-talk email discussion group is an easy way to keep up with cultural
competence in health care and to stay connected to other professional in the field.
Joint Commission Resources. Galanti, Geri-Ann, PhD, and Michael S. Woods, MD. Cultural Sensitivity A pocket Guide for
Health Care Professionals, 2nd ed. (2012).
The Joint Commission. One Size Does Not Fit All: Meeting the HealthCare Needs of Diverse Populations AmyWilsonStronks, Karen K. Lee, Christina L. Cordero, April L. Kopp, and Erica Galvez.
http://www.jointcommission.org/assets/1/6/HLCOneSizeFinal.pdf
National Consortium for Multicultural Education for Health Professionals fhttp://culturalmeded.stanford.edu/teaching
Patient Experience Body of Knowledge – Module Development | The Beryl Institute ©2012
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Small group self awareness activity at
http://culturalmeded.stanford.edu/pdf%20docs/Cultural_Competence_Self_Reflection_Exercise_Facilitator_Manual.pdf
HealthCare Chaplaincy- Cultural Sensitivity: A learning module for health care professionals- self awareness exercises
http://www.healthcarechaplaincy.org/userimages/Cultural_Spiritual_Sensitivity_Learning_%20Module%207-10-09.pdf
SUGGESTED ASSESSMENT QUESTIONS:
(Can be offered for each section or for the overall module)
Self Assessment
1. Name four components of self identity.
2. Name five components of a personal cultural assessment
Regulatory
1. Describe why the Joint Commission views effective communication, cultural competence and patient and family-centered care as
important components of safe, quality care.
2. Name one way that CMS is requiring hospitals to address cultural diversity.
Diverse Populations
1. Describe how cultural competency can improve patient safety through direct communication with individuals having language
proficiency barriers.
2. Describe two practices that can help address the needs of diverse populations.
Terminology
1. Define cultural awareness
2. Define culturally competent provider
Patient Experience Body of Knowledge – Module Development | The Beryl Institute ©2012
Improving the Patient Experience
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