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Cultural and Linguistic Competence and the CLAS Standards. Foundations and Definitions. Presenters. Cecily Rodriguez Director, the Office for Cultural and Linguistic Competence Office of Human Resources Development and Management Department of Behavioral Health and Developmental Services

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  • Cecily Rodriguez
    • Director, the Office for Cultural and Linguistic Competence
    • Office of Human Resources Development and Management
    • Department of Behavioral Health and Developmental Services
    • 804.786.5872
  • Dina Hackley-Hunt
    • Manager, Training and Staff Development
    • Blue Ridge Behavioral Healthcare
    • 3517 Brandon Avenue,Roanoke, VA 24018
    • 540.982.1427, ext. 2129
  • Nhat Nguyen
    • Substance Abuse Counselor II
    • Alcohol and Drug Services – Youth Outpatient Services
    • Fairfax-Falls Church Community Services Board
    • 14150 Parkeast Cir., #200
    • Chantilly, VA 20151
    • 703.499.6108
today s objectives
Today’s Objectives
  • Introduce the foundations of cultural and linguistic competence
  • Explore what cultural and linguistic competence mean to you
  • Introduce the CLAS Standards as a framework for how to integrate cultural competence into your organization
why cultural and linguistic competence
Why Cultural and Linguistic Competence?
  • Growing Population diversity
  • Disparities in access and outcomes
  • Limited staff with CLC expertise
  • Lack of organizational and systemic focus on CLC Efforts
  • Legal requirements related to language access
    • Title VI- Civil Rights Law
    • CLAS Standards 4-7
  • Federal and state expectations and accreditation criteria
what is cultural competence

National Center for Cultural Competence

And incorporate the above in all aspects of policy making, administration, practice, service delivery and involve systematically consumers, key stakeholders and communities.

definition of linguistic competence
Definition of Linguistic Competence

National Center for Cultural 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 persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities.

national standards on culturally and linguistically appropriate services clas
National Standards on Culturally and Linguistically Appropriate Services (CLAS)
  • Organized by themes:
    • Culturally Competent Care (Standards 1-3)
    • Language Access Services (Standards 4-7)
    • Organizational Supports for Cultural Competence (Standards 8-14)


  • Using generalizations to understand a group of people is productive and helps one gain insight into communication styles and behaviors
  • Using stereotypes to categorize or judge people is destructive and discriminatory
small group exercise
Small Group Exercise
  • Introduce yourself to your neighbor
  • Identify your culture to your neighbor
  • Share a generalization about your culture to your neighbor
  • Share a stereotype about your culture to your neighbor
changing face of the united states
Changing Face of the United States
  • Changing demographic
  • Aging baby boomers
  • Growth of racial and ethnic minority groups to overtake non-Hispanic White population within the next 45 years
  • By 2015, non-Hispanic Whites will be primarily elderly population
  • By 2050, racial and ethnic minority group will account for 90% of the total population growth
  • Demographic changes, including
    • Rapidly increasing population growth
    • Increased cultural and linguistic diversity
    • Aging population
  • Eliminate long-standing disparities in the health status of people of diverse race, ethnicity and cultural backgrounds
  • Improve the quality of services and health outcomes
  • Gain a competitive edge in the market place
  • Decrease the likelihood of liability/malpractice claims
  • To meet legislative, regulatory and accreditation mandates
cultural competence continuum
Cultural Competence Continuum






truth about competence
Truth about Competence
  • An awareness of diversity is NOT culturally competent
  • Only a handful of people or organizations can be culturally and linguistically competent
  • Organizations can be more competent and diverse in some areas than others
  • Organizations assume that their skills, services, approaches, or models apply to all cultures or groups

You saw a couple in an intimate love position, right?

Interestingly, research has shown that young children cannot identify the intimate couple because they do not have prior memory associated with such a scenario.

What they will see, however, is nine (small & black) dolphins in the picture!


So, I guess we've already proven you're not a young innocent child. Now, if it's hard for you to find the dolphins within 6 seconds, your mind is SO corrupted that you probably need help!

OK, here's help: look at the space between her right arm and her head, the tail is on her neck, follow it up. Look at her left hip, follow the shaded part down, it's another one, and on his shoulder..

clas 1 3
CLAS 1-3

Culturally Competent Care

culturally competent care
Culturally Competent Care

Standard 1

Health care organizations should ensure that patients/consumers receive from all staff member’s effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language

why be concerned multiple costs
Why be Concerned: Multiple Costs
  • Excess Preventable Deaths
  • Untreated Illness & Lower Achievement
  • Excess Hospital Admissions & Readmissions
  • Misdiagnosis & Poor Application
  • Community Suspicion and Mistrust
  • Staff Division and Conflict
  • Absence of Scientific Knowledge & Theory
barriers to help seeking
Barriers to Help-Seeking
  • Fear of hospitalization – high death risks
  • Fear of treatment – loss of control
  • Self-reliance & determination
  • Racist slights
  • Stigma
    • Embarrassment, shame or guilt
  • Cost, but Under-use especially among middle class Africa Americans with health insurance
summary of differences
Summary of Differences
  • Admission Rates
  • Diagnoses
  • Length of Stay
  • Involuntary Commitments
  • Recidivism/Readmissions
  • Suicide Rates
  • Medication Prescribed
  • Co-Morbid Conditions
  • Use of Ministers/Native Healers
  • Participation in Research Studies
  • Help Seeking Patterns
addressing the five a s of disparities
Addressing the Five A’s of Disparities


  • Does the service exist?


  • If service exists, are they easily usable?


  • Can the potential consumer afford the service?
  • Can potential providers afford to provide the service?
addressing the five a s of disparities27
Addressing the Five A’s of Disparities


  • Services produce desired clinical and functional outcomes?


  • Does the cultural community receive the services as in keeping with norms, values and practices of the community?
clinical and service delivery enhancements
Clinical and Service Delivery Enhancements
  • Fosters engagement and retention of populations of color in treatment
  • Service delivery strategies are incorporation of spiritual beliefs into the treatment of culturally different clients
  • Provision of services in the client's primary language through bilingual staff or interpreters
  • Use of culturally and linguistically appropriate assessment instruments
clinical and service delivery enhancements29
Clinical and Service Delivery Enhancements
  • Impacts the therapeutic relationship between the clinician and client, supporting the client's participation in treatment
  • Recognizes the dynamic interplay between "heritage" and "adaptation" in shaping human behavior
    • Heritage is the passing of tradition, beliefs, and values from older generations to younger generations
    • Adaptation is the ability to change one’s behaviors and attitudes to meet the demands of one’s environment
clinical and service delivery enhancements30
Clinical and Service Delivery Enhancements
  • Is able to utilize knowledge acquired about an individual's heritage and adaptation challenges to maximize the efficacy of assessment, diagnosis, and treatment
  • Internalizes this process of recognition, acquisition and utilization of cultural dynamics to routinely apply it to diverse groups

Care Coordination

Neighborhood Multi-Service Center

“The Services Mall” or “One-Stop Shop”

Faith-Based (Pastoral) Consortium

Primary Care Consortium

Hospital Consortium

Public School Consortium

Courts & Police Consortium

At all levels, cultural competence is not an endpoint, but an ongoing process of assessing people's needs and incorporating what is learned into the provision of services

evidence based practices ebps
Evidence-Based Practices (EBPs)
  • In culturally adapted service delivery, adjustments are made at the administrative, service delivery, and clinician levels to reflect the cultural knowledge, attitudes and behaviors of the target population
  • Culturally adapted care should be culturally competent care with ongoing assessments of needs and organizational resources
  • A key criticism of EBPs is that the research on which treatments' efficacy is evaluated rarely gives sufficient consideration to cultural and ethnic / racial factors
culturally competent practices
Culturally Competent Practices

Modify approaches to:

  • Assessment and diagnostic protocols
  • Treatment and interventions
  • Medications protocols
  • Education and counseling
  • Consulting with traditional/indigenous practitioners and natural healers
culturally competent practices34
Culturally Competent Practices

Modify approaches to:

  • Intake interview protocols
  • Disseminating information
  • Partnering with consumers and families
  • Consulting and collaborating with cultural brokers
  • Coaching and mentoring (i.e. home, school, work, recreational settings)
culturally competent practices35
Culturally Competent Practices

Empower consumers to undertake:

  • Advocacy
  • Partnerships
  • Advisory groups
  • Board membership
  • Program staff and consultants
  • Knowledge beacon
integrated community collaborative care
Integrated Community Collaborative Care


Primary Care

School Health



Substance Abuse

Pastoral Care

Dental Care

Mental Health

culturally competent care37
Culturally Competent Care

Standard 2

Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area

cost of incompetence
Cost of Incompetence
  • Organizations in the United States waste billions of dollars in lost production, human energy, and stability due to our inability to solve primitive problems of how we perceive, interpret, and respond to human differences
  • Without understanding and change these costs will continue to increase
why have a diverse workforce
Why Have a Diverse Workforce
  • New ideas and perspectives
  • Increased motivation and buy-in
  • Increased organizational retention
  • Mainstreaming new talent
  • Accurate representation
workforce development
Workforce Development
  • Cost Analysis
  • Benefit Analysis
  • Preparation/Staging
  • Action and Intentionality
what are the necessary steps in hiring diverse and culturally competent staff
What Are the Necessary Steps in Hiring Diverse and Culturally Competent Staff?
  • Become versed in how cultural and linguistic competency is reflected in the mission statement, policies, practices and procedures of the agency
  • Frame diversity and cultural and linguistic competency as essential components in how the agency measures excellence in service delivery
  • Recognize how our own background influences how we view difference (HOMEWORK)
  • Create an environment that actively fosters acceptance and respect for difference
abcs to increase diversity
ABCs to Increase Diversity
  • Determine program diversity, recruit culturally diverse staff that ideally reflects the cultural diversity of the individuals receiving services
  • Strategically post vacancy announcements in culturally diverse environments such as culturally specific community news papers, Web sites, list serves, multicultural agencies, and professional minority associations
  • Actively recruit a racially and culturally diverse staff as an ongoing practice
abcs to increase diversity43
ABCs to Increase Diversity
  • Diversify hiring panels
  • Include cultural competence as a requirement in job descriptions
  • Standardize ways to assess a candidate’s ability to deliver culturally competent services
  • Hire staff who exhibit skills in culturally competent practice
an effective program organization
An Effective Program-Organization
  • Distinguish cultural backgrounds, idioms and accents
    • Know about specific cultural dynamics but critical to stay away from simplistic solutions (one style does not fit all)
an effective program organization45
An Effective Program-Organization
  • Budget commitment to support Culturally and Linguistically Appropriate Services (CLAS) standards
  • Short but regular in-service sessions for employees that always includes a cultural competency topic
  • Ensures culturally-relevant policies
where is cultural competence needed most
Where is Cultural Competence Needed Most?
  • Agency Vision & Mission
  • Organizational Values
  • Organizational Policies
  • Standards & Guidelines for Service
  • Service Delivery – Assessment & Interventions
  • Hiring Patterns & Staffing
  • Supervision
  • Training & Re-training
  • Agency Location
improvements to cultural competency
Improvements to Cultural Competency
  • Create strategic plan to ensure follow-through
  • Connect cultural competence to public image
  • Create cultural competent subcommittee as part of Quality Improvement Committee
  • Use the same processes for performance improvement and corrective action
improvements to cultural competency48
Improvements to Cultural Competency
  • Tie cultural competence to cost
  • Include cultural competence in training curriculum, especially to key managers and Board members
  • Decrease the assumption that cultural competence is Affirmative Action – it’s not about African-Americans
  • Develop standards and guidelines
culturally competent care49
Culturally Competent Care

Standard 3

Health care organizations should ensure that all staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery

why be concerned multiple costs50
Why be Concerned: Multiple Costs
  • Excess Preventable Deaths
  • Untreated Illness & Lower Achievement
  • Excess Hospital Admissions & Readmissions
  • Misdiagnosis & Poor Application
  • Community Suspicion and Mistrust
  • Staff Division and Conflict
  • Absence of Scientific Knowledge & Theory
why be concerned multiple costs51
Why be Concerned: Multiple Costs
  • Ethical Conflict: Professional & Personal
  • Increased Taxes & Agency Budgets: Waste
  • Loss of Input from Special Markets: Volunteers/Policy
  • Clinical Dropouts
  • Cultural Malpractice
  • Public Customers are Disproportionately Persons of Color!
cultural dimensions
Cultural Dimensions
  • Individualistic Culture
    • High value on autonomy, initiative, creativity, and authority in decision making
    • Individual interests supersede group interests
    • Any group commitment is a function of a perceived self-benefit
    • Conflict is inevitable and should not be perceived with shame
cultural dimensions53
Cultural Dimensions
  • Collectivist Culture
    • High value on group above individual
    • Group conformity and commitment is maintained at the expense of personal interests
    • Harmony, getting along and maintaining “face” are seen as crucial
    • Conflicts are avoided
    • Exists everywhere in the world except in USA, Canada, Western Europe, Australia, and New Zealand
conflict prevention and resolution
Conflict Prevention and Resolution
  • Know yourself and your own culture
  • Learn others expectations
  • Check your assumptions
  • When in Rome…ask questions
  • Listen
  • Consider the Platinum rule (“Treat others like THEY want to be treated”)
  • All conflict is multi-cultural
useful techniques
Useful Techniques:
  • Bind Cultural Competence to Vision/Goals
  • Connect Cultural Competence to Public Image
  • Link Cultural Competence to Public Trust
  • Tie Cultural Competence to Costs
  • Include Cultural Competence in the Training Curriculum
  • Show how Cultural Competence is Useful to Save Money
  • Develop Standards and Guidelines
useful techniques56
Useful Techniques:
  • Decrease the Assumption that Cultural Competence is Affirmative Action
  • Decrease the Assumption that Cultural Competence is About Black People
  • Provide Training and Education in Cultural Competence for Key Managers in the Organization and Board Members
  • Develop a Plan of Action with Education, Licensure, and Accreditation
useful techniques57
Useful Techniques:
  • Non-Blaming Approach
  • Focus on Cost Savings/Marketing Framework
  • Focus on Service Improvements/Quality/Data
  • Acknowledge Existing Competencies
  • Understand Resistance/Nature/Origins
  • Recognize Weaknesses in Cultural Competence
  • Establish a Realistic Schedule for Change
clas 4 7
CLAS 4-7

Language Access Services

why do we need to offer language services62
Why Do We Need to Offer Language Services?
  • Interpreter Training Program at Catholic Charities – Immigration and Refugee Services:
    • Tested 2006 - 160 “bilinguals”
    • 51 applicants failed the test 32 %
why do we need to offer language services63
Why Do We Need to Offer Language Services?

The Institute of Medicine of the National Academies say- individuals who do not receive effective health communication tend to:

  • Fail to enroll in health coverage programs
  • Fail to make certain that their dependents are covered
  • Neglect to seek preventive health care
  • Make medication and treatment errors b/c they cannot follow patient instructions
why do we need to offer language services64
Why Do We Need to Offer Language Services?

The Institute of Medicine of the National Academies say- individuals who do not receive effective health communication tend to:

  • Use emergency department services as their primary source of health care
  • Be hospitalized
  • Remain in the hospital for longer periods of time because they cannot care for themselves at home
why do we need to offer language services65
Why Do We Need to Offer Language Services?

Some groups are more likely than others to have limited health literacy. Certain populations are most likely to experience limited health literacy:

  • Adults over the age of 65 years
  • Racial and ethnic groups other than White
  • Recent refugees and immigrants
  • People with less than a high school degree or GED
  • People with incomes at or below the poverty level
  • Non-native speakers of English

National Action Plan to Improve Health Literacy

what does the law say
What Does The Law Say?
  • The Civil Rights Act of 1964 says that no person shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination based on race, gender, ethnicity or national origin under any program or activity receiving Federal financial assistance"
  • The Social Security Act prohibits discrimination in the Maternal and Child Health Services Block Grant
  • The Public Health Service Act prohibits discrimination in the Community Mental Health Services Block Grant and Substance Abuse Prevention and Treatment Block Grants
  • The Public Health Service Act prohibits discrimination in the Preventative Health and Health Services Block Grants
covered entities
Covered Entities

Include any state or local agency, private institution or organization, or any public or private individual that

  • Operates, provides or engages in health, or social service programs and activities, and
  • Receives Federal financial assistance from HHS directly or through another recipient/covered entity
examples of covered entities
Examples of Covered Entities
  • Hospitals
  • nursing homes
  • home health agencies
  • managed care organizations
  • universities and other entities with health or social service research programs
  • state, county and local health agencies
  • federally-funded programs for families, youth and children
  • public and private contractors
  • subcontractors and vendors
  • Physicians
  • and other providers who receive Federal financial assistance from HHS
what does language access mean
What Does “Language Access” Mean?

Ensuring that people who don’t speak, read, or write in English, or who have some other communication barrier receive EXACTLY the same opportunity to understand the information provided to them as someone who does speak, read, and write in English

what are language services
What are Language Services?
  • Individuals Right to Know
  • Interpreting
  • Translation
  • Assistive Technology/Communication Tools
  • Signage
  • Way-finding
  • Community Involvement
  • Training
  • When information is communicated orally
  • There are four roles for an interpreter
    • Conduit- No additions, no omissions, no editing or polishing
    • Clarifier- Adjust register, makes pictures of terms
    • Culture Broker- Provides necessary cultural framework
    • Advocate- Action usually taken outside the interpreted interview
best practice
Best Practice

The Pre-Session

A short informational conversation held before the interpreting begins

best practice74
Best Practice

During a session

Interpreter sits slightly behind the patient when appropriate




best practice75
Best Practice

The provider can do a lot to enhance the quality of the session

Empower the Patient

Greeting in Native Language

Body language

Casual Conversation

Eye Contact (When appropriate)

Remember that everything said is interpreted

provider s role
Provider’s Role

Ask questions directly to your patient

Ask open ended questions

Speak about one problem or symptom at a time

Avoid using slang or idioms

“This is a hard one to call”

“I’m feeling under the weather”

“We’re going to lick this”

provider s role77
Provider’s Role

Watch for changes in patient’s expression

If a 10 second explanation is summed up in few words, ask for clarification

If a response doesn’t make sense, ask for more information

Keep an open mind – logical connections may be different between different cultures

why use trained interpreters
Why Use Trained Interpreters?
  • Accurate information
  • Patient’s full comprehension
  • Patient’s consent and autonomy
  • Patient’s education about U.S. health care system improves
advantages continued
Advantages continued….

More disclosure and greater understanding of underlying issues

More information for complete health history

Greater ease of diagnosis

Greater buy-in for treatment plans

Stronger relationships between provider and individual

untrained interpreters
Untrained Interpreters

Unknown language competency

No orientation to medical interpretation

No or little knowledge of medical terminology

Previous relationship with patient

Relationship with patient could compromise the quality of the session

children as interpreters
Children as Interpreters

Imbalance of power

Lack of Maturity

Lack of Language Proficiency

Uncomfortable role

Negates confidentiality

  • Although written documents can be a valuable way to communicate information, every language is a unique, purposeful set of visual, auditory or tactile symbols of communication expressing underlying cultural practices, values and beliefs
  • The conventions and text elements (e.g., title, tone, voice) for each language are dictated by cultural norms associated with the underlying communicative purpose
signage and way finding
Signage and Way Finding

Other than serving as the big logo for an organization, the primary purpose of a signage is to direct the outsiders and visitors as to what the organization stands for, but once again, there are a lot other elements attached to the determination of this direction

  • How to work effectively with an interpreter
  • Cross cultural communication
  • Communicating complex information to individuals who possess low literacy skills or who are not literate
  • Identifying individuals with literacy and health literacy barriers to communication
sustaining language access services
Sustaining Language Access Services
  • Ensure that interpreting and translating services are considered mission critical
  • Budget for those costs as you would any overhead and consider them the cost of doing business, not just a luxury
  • Request/require all bi-lingual staff to become certified interpreters and pay them for that additional skill when the perform it
  • Train ALL staff to work effectively with interpreters
elements of an effective language assistance plan
  • Identifying LEP individuals who need language assistance
  • Language assistance measures (such as how staff can obtain services or respond to LEP callers)
  • Training staff
  • Providing notice to LEP persons (such as posting signs)
  • Monitoring and updating the LEP plan
section iii

Section III

The “Shoulds” of CLAS

what is organizational cultural competence
What is Organizational Cultural Competence?
  • A defined set of values and principles that enable systems to work effectively cross-culturally
  • The capacity to value diversity, conduct self-assessment, manage the dynamics of difference, acquire and institutionalize cultural knowledge, and adapt to diversity and the cultural contexts of the communities served
  • The incorporation of the above in all policymaking, administration, practice, and service delivery, and the systematic involvement of consumers, key stakeholders, and communities
more than correctness
More than correctness..

“The danger is that people may mistake what is basically a change in vocabulary for a change in behavior, practice and attitudes. While practically all Americans have learned to talk inoffensively, not enough have learned to think differently nor act positively.”

Whitney Young

(U.S. director of the National Urban League 1921-1972)

organizational supports
Organizational Supports

How to make it work at your agency

standards 8 13 recommended for adoption as mandates
Standards 8-13Recommended for adoption as mandates
  • Standard 8Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services
best practice dictates
Best practice dictates…

Everyone in your worksite- from a “new hire” to an “about to retire” knows that in THIS organization –

We honor our clients and one another

  • Baby steps…
  • Need buy-in from the top down
  • Have a go-to person
  • Get everyone involved
  • Keep at it!
standard 9
Standard 9
  • Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations
critical components of a clc plan include
Critical Components of a CLC Plan Include:
  • Population Assessment
  • Organizational & Service Assessment
  • Evaluation & Quality Assurance
  • Action Plan
agency assessments abound
Agency Assessments Abound!
  • Building Bridges
  • National Center for Cultural Competence
standard 10
Standard 10
  • Health care organizations should ensure that data on the individual patient's/consumer's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated
standard 11
Standard 11
  • Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.
standard 12
Standard 12
  • Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities
principles of community engagement
Principles of community engagement:
  • Know the community’s make-up
  • What are the needs and issues affecting the specific cultures?
  • Find cultural brokers to introduce you to key informants
principles continued
Principles, continued…
  • Be present in the community
  • Make sure the relationships are reciprocal
  • Relationships take time to be built- one negative event can destroy them
standard 13
Standard 13
  • Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers
where are those forms
Where are those forms???
  • Make sure your employees know that forms are available and where to find them!
standard 14 suggested for voluntary adoption
Standard 14(Suggested for voluntary adoption)
  • Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information

Using Standards 12 and 14

question of the day
Question of the Day

Why is yogurt good for you?

Yogurt is good for you because it has live cultures