New Standards Will Help Organizations Improve Quality of Care and Reduce Health Disparities

New Standards Will Help Organizations Improve Quality of Care and Reduce Health Disparities

Health and Human Services (HHS) recently released enhanced National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care—a blueprint to help organizations improve health care quality in serving our nation’s diverse communities.

The enhanced standards, developed by the HHS Office of Minority Health, are a comprehensive update of the 2000 National CLAS Standards and include the expertise of federal and non-federal partners nationwide to ensure an even stronger platform for health equity. The enhanced National CLAS Standards are grounded in a broad definition of culture—one in which health is recognized as being influenced by factors ranging from race and ethnicity to language, spirituality, disability status, sexual orientation, gender identity, and geography.

“We are making great strides in providing quality care and affordable coverage for every American, regardless of race or ethnicity or other cultural factors because of the Affordable Care Act,” said HHS Secretary Kathleen Sebelius. “The Enhanced National CLAS Standards will help us build on this ongoing effort to ensure that effective and equitable care is accessible to all.”

A key initiative in the department’s effort to reduce health disparities, the update marks a major milestone in the implementation of the HHS Action Plan to Reduce Racial and Ethnic Health Disparities.

Long existing inequities in health and health care have come at a steep cost not only for minority communities, but also for our nation. As cited in a recent report from the HHS Agency for Healthcare Research and Quality, the burden of insufficient and inequitable care related to racial and ethnic health disparities has been estimated to top $1 trillion.

“Disparities have prevented improved outcomes in our health and health care system for far too long,” said Assistant Secretary for Health Howard K. Koh, MD, MPH. “The enhanced CLAS Standards provide a platform for all persons to reach their full health potential.”

Specifically, the enhanced standards provide a framework to health and health care organizations for the delivery of culturally respectful and linguistically responsive care and services. By adopting the framework, health and human services professionals will be better able to meet the needs of all individuals at all points of contact.

“Many Americans struggle to achieve good health because the health care and services that are available to them do not adequately address their needs,” said J. Nadine Gracia, MD, MSCE, Deputy Assistant Secretary for Minority Health and Director of the HHS Office of Minority Health. “As our nation becomes increasingly diverse, improving cultural and linguistic competency across public health and our health care system can be one of our most powerful levers for advancing health equity.”

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How to Treat Your Patients With CLAS

Nurses who have been following the progress of the federal Office of Minority Health (OMH)’s landmark project to develop a set of comprehensive national standards for culturally and linguistically appropriate services (CLAS) in health care know that the final version of the standards was officially published in the Federal Register in December 2000. But did you know that OMH has also produced a Final Report on the standards in a handy paperback book format that makes an excellent desktop resource for nurses in clinical practice who want to help their health care institutions implement the CLAS guidelines?

The 14 standards–some of which are voluntary recommendations while others are mandates under Title VI of the Civil Rights Act for any health care organization that receives federal funds—cover such areas as recruiting and retaining a culturally diverse staff, training staff to deliver culturally and linguistically competent services, and providing patients who have limited English language proficiency with competent language assistance services.

The Final Report not only summarizes the CLAS standards but also contains a wealth of information to help nurses in clinical settings understand them, interpret them and apply them to their practice and to their facility’s particular cultural competency needs. The book includes a history of the project, an in-depth discussion of each standard and the issues involved, examples of strategies for implementing the standards, a bibliography, a glossary and more.

“I don’t want to go out on a limb and say it’s ‘everything you want to know about cultural competence,’” the CLAS project’s principal investigator, consultant Julia Puebla Fortier, founder of Resources for Cross-Cultural Health Care in Silver Spring, Md., told Minority Nurse. “But an awful lot of what you want to know about cultural competence is contained in this report.”

Fortier, who is of Mexican American and Native American descent, offers this advice for how nurses can best use the Final Report—which, at 180 pages, may seem a little weighty and intimidating at first glance. “The standards themselves, which are published at the very beginning of the report, are obviously the first place to start. It’s really helpful to get a sense of the overall framework the standards are trying to describe, because in a way, they are describing an ideal culturally competent institution.

“Implementing the standards must be a step-by-step process,” she continues. “Depending on what is already going on in the organization, what the strongest needs are, clinicians on the front lines can look at the condensed form of the standards and say, ‘Where do we want to focus our energies first? Do we want to start out by doing an assessment, or by instituting data collection practices? Do we want to tackle interpreter issues?’ You can take a couple of things that you want to focus on and then go to the report’s discussion section.”

That section, says Fortier, is “very useful for helping you understand the depth of the implementation issues, such as what some of the model programs are and what is involved in their execution. It’s not a step-by-step guideline, but it lays out all of the most important issues, both from the perspective of what can be achieved and what possible complications could be encountered. As for the section on the background and purpose of the CLAS project, it’s a very useful tool for nurses who are trying to make the case for their institution to pursue cultural competence in general.”

For a free copy of the CLAS Final Report, contact the Office of Minority Health Resource Center (OMHRC) at (800) 444-6472. If you are interested in simply reading the final CLAS standards without any of the supplemental information contained in the report, the OMHRC Web site has a direct link to the Federal Register version.

CLAS Action

CLAS Action

Cultural competency expert Josepha Campinha-Bacote, RN, PhD, CS, CNS, CTN, FAANCultural competency expert Josepha Campinha-Bacote, RN, PhD, CS, CNS, CTN, FAAN

The Office of Minority Health’s national standards for Culturally and Linguistically Appropriate Services (CLAS) in health care have been a matter of public record ever since the final version was published in the Federal Register in December 2000. Getting the standards into the register was a milestone, but some nursing leaders are concerned that the next step in the process–the actual implementation of CLAS in the nation’s health care facilities–is having trouble getting off the ground. While some major hospitals and health insurers have indeed begun to implement the standards, it appears that many health care providers, including nurses, have still never heard of CLAS.

Josepha Campinha-Bacote, RN, PhD, CS, CNS, CTN, FAAN, president and founder of Transcultural C.A.R.E. Associates in Cincinnati, feels progress has been slow when it comes to spreading the word about CLAS among the nursing ranks. Campinha-Bacote, who was one of two nurses who sat on the 22-member National Advisory Committee on CLAS, has given over 1,000 lectures to health care organizations since 1991. Sixty percent of those, she estimates, are to nursing groups. Campinha-Bacote says she polls her audience, which can range from 300 to 6,000 people, on current nursing topics–and for the past year and a half, she has been asking about CLAS. 

“Ninety-eight percent of the time, no one has heard about it,” she complains. “And when I do get people raising their hands, it is usually just one or two. The sad part is, here we are almost two years later, and nurses still don’t know about CLAS.”

Before it can be determined if health care providers are implementing CLAS in their institutions, Campinha-Bacote says, “the first thing we need to do is get nurses, as well as other health professionals, to know the standards exist.” Despite the easy-to-remember acronym, she argues, CLAS has not become a mnemonic that has registered in care providers’ minds.

Why is Campinha-Bacote, who is a black nurse of Cape Verdean descent, so concerned about this? Because, she points out, the federal government’s whole intent when it created the CLAS standards was to improve access to care, quality of care and, ultimately, health outcomes for members of racial, ethnic and cultural minority groups.

There are 14 CLAS standards, some of which are mandatory under Title VI of the Civil Rights Acts for any health care organization that receives federal funding, while others are voluntary. The standards are organized into three areas: culturally competent care, language access services for patients with limited English proficiency, and organizational support for cultural competence.

Getting the Ball Rolling

Guadalupe Pacheco, MSW, who was the project officer for the development of the CLAS standards, feels that the move to implement CLAS in America’s health care institutions is gaining momentum. “It is hard to gauge how much progress is being made,” admits Pacheco, the Office of Minority Health’s public health advisor and special assistant to the director. “But I think because of the changing demographics of this country, especially in those states where the growth of cultural diversity has been really phenomenal, health care facilities are starting to look at this as something that will add value to their service delivery programs.”

Neonatal nurse practitioner Cheryl Nicka, RN, CNNPNeonatal nurse practitioner Cheryl Nicka, RN, CNNP

Pacheco, who is Latino, points to the state of North Carolina, which has had about a 400% increase in its Latino population since the 1990 census. “A lot of health care programs don’t have the structure in place to meet the demand right now, so they are a little behind the eight ball. They don’t yet have a bilingual or bicultural staff, or they don’t have interpreters or training programs for the interpreters,” he says. “But I also know one major HMO that is going to implement the standards and that is Kaiser Permanente in California.”

Pacheco agrees that there needs to be a greater push to get the word out to nurses–for example, through national nursing professional associations and minority nurse associations. “Those health care institutions that have been aggressive in implementing the standards recognize that CLAS applies to every health care practitioner,” he notes. “They are probably making sure when they do their in-service or their overview that they are approaching the standards, and I think nurses could be a major player in that process.”

Some experts in culturally competent care argue that health care facilities would be much more motivated to implement CLAS if the standards were 100% mandated by law. But, Pacheco contends, “OMH is not a regulatory agency. What we were trying to do in creating these recommended standards was to encourage policy-makers and federal, state and local legislators to take the lead. If they feel [the CLAS standards] should be mandates, they should go ahead and push for it, and then look at how they can start incorporating the principles into the accreditation and credentialing processes.”

Getting the Word Out

Maria Teresa (Tere) Villot, RN, BSN, president of the Philadelphia Chapter of the National Association of Hispanic Nurses (NAHN), reports that since the December 2000 publication of the final report on the CLAS standards, there has been an effort to incorporate the guidelines in her region. Since she works for the federal government at the Philadelphia Veterans Affairs Medical Center, Villot became aware of CLAS when she read about it in the Federal Register. However, she adds, “I am not surprised that a lot of nurses in the private sector still don’t know about it.”

Philadelphia’s Latino population is growing, Villot says, and there is a big push to hire more Hispanic nurses who are bilingual and bicultural. She cites the city’s Temple University Hospital, which has a unit that is completely bilingual and bicultural, from the housekeepers to the nurse managers, as a good example of an organization that is being proactive about providing culturally and linguistically appropriate services to meet changing community needs.
Like Pacheco, Villot thinks nursing leaders and associations could play a key role in disseminating information about CLAS to the nation’s RN workforce. Raising the public’s awareness is important as well, she adds. “Our organization does a lot of community health fairs and lectures. We go to churches and senior citizens’ homes and to the schools. Any way we can get the word out would be good.” 

One way to increase nurses’ awareness of the CLAS standards within the health care setting, Villot suggests, is through in-services. Her position at the VA facility requires her to do 40 hours of mandatory classes a year. “That would be an excellent way to deliver information about CLAS,” she says.
The NAHN chapter president believes it is appropriate that the majority of standards are not mandated by law. “I think when people are mandated to do things, you get more resistance,” she argues. “If you are a conscientious health care professional, you know what your community needs, what your patients need and how to deliver it.”

Getting it in Writing

Prior to being interviewed for this article, Cora C. Munoz, RN, PhD, was under the impression that all 14 CLAS standards were mandatory for health organizations receiving federal funds. She first heard about the standards in 1998 when they were being drafted. During the public comment period, as a commissioner with the Ohio Commission on Minority Health, she facilitated a focus group that reviewed the proposed standards and provided feedback that was forwarded to the CLAS regional task force in Chicago.

Munoz, who is a member of several nursing associations, including the Philippine Nurses Association of America, believes the reason why many working RNs are unaware of these new standards is because their hospital administrations have not shared the information with them. She agrees that there is a critical need for staff training in this area, but stresses that the CLAS standards should be taught in the context of overall cultural competency training, not as a stand-alone entity.

“This training needs to be mandatory for all health care providers,” she says. “We need nurses to share this information with other nurses so that its implication to practice can be emphasized. These standards are so important because for a long time, there has been a lack of clarity in the definition of cultural competence. These standards give health care organizations some directions and very specific guidelines to follow on how to provide culturally competent services.”

Unlike Villot, Munoz feels the CLAS standards should be adopted as law. The biggest challenge, she explains, is how to ensure that health care institutions will comply with the standards.

“There must be a mechanism in which organizations become accountable if they do not progress towards cultural competence,” she says. “Accrediting agencies that include this in their criteria are commendable. All health care providers and educators in the helping professions need to incorporate this information into their curricula to ensure that our future health professionals are knowledgeable about how to enhance cultural competence in providing health care services.”

Getting the Whole Story

Cheryl Nicks, RN, CNNP, president of the New Orleans Chapter of the National Black Nurses Association, is one of the nurses who had not heard of CLAS by its formal name prior to an interview request from Minority Nurse. After reading up on the standards, she thinks that one reason why nurses might not know about them is that many health care facilities follow parts of the standards but are not looking at the whole picture of how to deal with cultural and linguistic differences. “I feel that if people think they have one piece of the puzzle, they are achieving their goal,” she adds.

In her work as a neonatal nurse practitioner, Nicks has seen many examples of how health professionals’ failure to understand a minority patient’s culture can have a negative impact on the care that patient receives.  She points to a recent case that involved a premature baby. When it was time for the baby to be discharged from the hospital, the child’s mother was in jail, but the baby’s uncle said he and his wife would take the child home. “The child had some minor medical problems and needed somebody who was able to care for a baby at home,” she recalls. “The uncle, who was African American, was very religious and said he believed in healing through burning candles and laying on of hands.”

When he made this statement to a Caucasian nurse, Nicks continues, the nurse thought the man was crazy. “She wasn’t comfortable letting the baby go home with him, and she talked to her manager. They wanted the man to take all of these courses and get certified in CPR. They asked my opinion, and I said I didn’t see anything wrong with [what he said].”

Burning candles and the laying on of hands are part of the African-American culture, Nicks says. “Had these nurses had some knowledge of other people’s cultures, they would not have become so alarmed by this man.”

Mental health nurse Marvel Davis, RN, BSN, MSN, the immediate past president of the Southern Connecticut Black Nurses Association, says she too had not heard of CLAS by its official name. But, she adds, at Yale New Haven Psychiatric Hospital, the facility where she works, cultural competence is something that is supported and encouraged: “Staff members all up and down the scale are acknowledging the importance of being culturally competent and aware when giving care to patients from any setting.”

The health care industry in general, Davis says, is finally realizing that it needs to ask patients from diverse cultures what their perspective is, rather than always assuming it has the answers. “We may have the medical answers, but the patient doesn’t come here in isolation,” she points out. “To arrive at those answers, we need to have some understanding of all the other pieces of what is going on with the patient, including the social and cultural ones.”
Like the other experts interviewed for this article, Davis believes the best way to get nurses involved in implementing CLAS is to inform them about the standards through nursing organizations, credentialing bodies and nursing schools’ curricula. At her hospital, Davis is a liaison for nursing students from several area schools, including Yale University, her alma mater. She plans to talk about the CLAS standards with the professors and recommend that they promote them in their classes.

“That’s how it becomes a reality,” she maintains. “If you are teaching it, they will learn it and use it.” Davis, who is the historian of the National Black Nurses Association, also plans to promote CLAS at the association’s next board meeting.

Getting Motivated

Ronald Greene, RN, BSN, a case manager at Massachusetts General Hospital in Boston (a member of Partners HealthCare System) and chairman of the Association of Multicultural Members of Partners, also admits to never hearing about CLAS in a formal sense. But after looking over a copy of the standards, he says Mass General follows the principles.

Mental health nurse Marvel Davis, RN, BSN, MSNMental health nurse Marvel Davis, RN, BSN, MSN

“The institution is really addressing these standards, and some of the changes that have occurred as a result are truly phenomenal,” states Greene, who is also president of the New England Chapter of the National Black Nurses Association. As an example, he points to some eye-opening workshops on cultural sensitivity that have been held at the hospital.

For almost six years, Deborah Washington, RN, MSN, has served as the director of diversity for patient care services at Mass General. Even though this was a newly created position, she notes that “the hospital has been paying attention to cultural diversity for much longer than that.”

Washington, who is African American, participated in one of the public comment meetings on the draft version of the CLAS standards. Today, she says, “I use the standards to reinforce for people that the reason we provide culturally appropriate services is not just because it is a nice thing to do, or because diversity helps improve the bottom line. [Having federally recommended guidelines] puts some punch behind it. And it also makes a difference for people to know that the government is paying attention.

“What I like about the CLAS standards is that they not only address the tangible benefits of diversity but also the intangibles,” she continues. “I think that is very powerful.”

Still, Washington has found that many of the nurses at Mass General have not heard about CLAS. “When I bring it up, it is news to them,” she says, adding that she would question how effectively the standards have been promoted to the nation’s nursing population.

Getting it Done

Rick Zoucha, RN, APRN, BC, DNSc, CTN, president of the Transcultural Nursing Society (TCNS), also attended one of the national hearings held during the public comment period for CLAS. Culturally competent care, he believes, has not been given the priority it deserves. For example, he has met many health professionals who have never heard of transcultural nursing, and he suspects the same is probably true for CLAS.

With more than 2.6 million licensed RNs currently practicing in the United States, Zoucha feels nurses should be taking the lead in carrying the banner for CLAS.

“We are the largest health care provider group in the country when you look at sheer numbers,” he explains. “We are the ones who spend the intimate time with the patients. We are with patients 24 hours a day and we are the ones that go into the home. Nursing is all about building relationships with patients, and what better way to do that than by understanding, accepting and actually going beyond acceptance of another person’s culture? I think nurses are a natural [to get the word out about CLAS] just because of the nature of the work we do.”

Washington agrees. “Not every health care organization has a formal diversity program,” she says. “But even if there isn’t someone setting the stage organizationally, a nurse can promote cultural competence as a personal commitment. It’s important for nurses to know about these federal standards so they’ll know that they are not alone. If you want to be an advocate for culturally and linguistically competent care, CLAS gives you a tool.”

Cultural Competence to Become Part of Hospital Accreditation Process

Have you ever wished that hospitals had more of an incentive to provide culturally and linguistically competent patient care? Or that standards for providing culturally and linguistically appropriate services (CLAS) were not just optional guidelines but real requirements that health care facilities have to pay attention to—like the Joint Commission’s standards for hospital accreditation? Well, the Joint Commission has heard you and is now working to develop the first-ever accreditation standards for the provision of culturally competent patient-centered care.

Launched in August 2008, the 18-month standards development project will build upon the research framework of the Joint Commission’s ongoing Hospitals, Language and Culture: A Snapshot of the Nation study, which has been examining how a sample of 60 hospitals across the country are providing health care to culturally and linguistically diverse patient populations. The study’s findings, published in reports such as the recent One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations, have shown that while many health care facilities are trying to meet their patients’ cultural and language needs, the practices being used vary widely from hospital to hospital.

“Hospitals face many challenges in caring for a rapidly changing patient population,” says Paul M. Schyve, MD, Joint Commission senior vice president and co-director of the project. “Sensitivity and responsiveness to cultural and language needs impact the quality of care, patient safety, and patient and family satisfaction. [This] initiative will provide a firm foundation for standards that foster culturally competent patient-centered care.”

Funded by a grant from the Commonwealth Fund, the project will examine how diversity, culture, language and health literacy issues can be better incorporated into current accreditation standards or drafted into new requirements. The Joint Commission will then collaborate with the National Health Law Program (NHeLP) to develop an implementation guide to help hospitals prepare for the release of the cultural competence standards, which are targeted to take effect in 2011.
To guide this important work, the Joint Commission has assembled a 26-member Expert Advisory Panel that will review available evidence-based best practices and identify principles that can be the basis for new and revised standards. The multidisciplinary panel includes nationally recognized minority nursing leaders such as Debra A. Toney, PhD, RN (president, National Black Nurses Association) and Faye Gary, EdD, RN, FAAN, Medical Mutual of Ohio Professor for Vulnerable and At-Risk Persons at Case Western Reserve University’s Frances Payne Bolton School of Nursing.

For more information about the Joint Commission’s initiative to develop culturally competent patient-centered care standards, visit (click on “Patient Safety,” then “Hospitals, Language and Culture”).