cultural and linguistic competence in healthcare: the case ... and...cultural and linguistic...

Cultural and Linguistic Competencein Healthcare: The Case of AlabamaCeneral HospitalsMarilyn V. Whitman, PhD, lecturer. Management and Marketing Department, TheUniversity of Alabama, Tuscaloosa, and Juliet A. Davis, PhD, associate professor.Management and Marketing Department, The University of Alabama

E X E C U T I V E S U M M A R YAs the nation's foreign-born population continues to increase, the importance ofunderstanding cultural, ethnic, and religious differences to combat racial/ethnicdisparities in access to and utilization of healthcare services intensifies. In Alabama,specifically, the shifting migration patterns and the growth of the foreign-born popu-lation have altered the state's demographics, introducing new cultures and languagesto this traditionally biracial state. Because Alabama general hospitals are not immuneto the widespread cost, access, and quality paradox that plagues every healthcareorganization, they too must consider the value of cultural and linguistic competencein providing high-quality, cost-effective care.

This exploratory study examined the awareness of and preparedness for thediversifying patient population of general medical and surgical hospitals in Alabama.Questionnaires were mailed to the chief executive officers of 101 general medicaland surgical hospitals. A sample of 53 respondents provided data on the measuresand resources that the hospitals currently use to meet cultural and linguistic compe-tence standards. Our findings indicate that, although these hospitals are taking theinitial steps to prepare for the diversifying patient population, a great deal needs tobe accomplished before they are able to meet the National Standards for Culturally andLinguistically Appropriate Services in Health Care established by the U.S. Department ofHealth and Human Services's Office of Minority Health.

For more information on the concepts in this article, please contactDr. Whitman at [email protected].

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CULTURAL AND LINGUISTIC COMPETENCE IN HEALTHCARE

R ecent literature on the proper treat-ment of foreign-born patients

stresses the need for healthcare pro-viders to be aware and to have anunderstanding of different cultures. Asthis segment ofthe population grows,presently accounting for more than 12percent of the nation's total popula-tion, the need to eliminate racial/ethnicdisparities in access to and utilizationof healthcare services intensifies. Theimportance of understanding cultural,ethnic, and religious differences in thedelivery of healthcare has gained vastattention, as racial and ethnic disparitiesin healthc?' . nave continued to growand the focus of educators, policymak-ers, insurers, and providers has turnedtoward ensuring the efficacy and qualityof care given to diverse patient popula-tions (Betancourt et al. 2005).

People's beliefs and practices relatedto health and illness are infiuenced bytheir culture. Luckmann (1999, 22) ar-gues that culture shapes an individual'sworld view and "provides each personwith specific rules for dealing with theuniversal events of life—birth, mating,child-rearing, illness, pain, and death."Gulture affects an individual's ideasabout illness prevention, expectationand acceptance of treatment, and degreeof comfort with his or her healthcareprovider. Therefore, it is crucial for pro-viders to be aware ofthe similarities anddifferences in cultures; to know culturalvalues, beliefs, and practices; and torespect patients and their diversity. Withsuch a basis, providers can modify theirpractices to improve the delivery of care.

A number of studies show thatmisunderstandings that stem from cul-tural differences and language barriers

have resulted in poor patient-providerrelationships, incorrect diagnosis, lackof informed consent, a greater numberof tests performed, decreased patientcompliance with physician directivesand follow-up care, increased costs,lower patient satisfaction, and even mal-practice suits (Baker, Hayes, and Fortier1998; Hampers et al. 1999; Garras-quillo et al. 1999; Ferguson and Gandib2002; Herndon and Joyce 2004; Ku andFlores 2005). In 2001, acknowledg-ing the challenges associated with theincreased use of public-funded servicesas a result ofthe growth ofthe foreign-born population. President Glintonsigned into law "Executive Order 13166:Improving Access to Services for Personswith Limited English Proficiency." Thelaw mandates all agencies and organi-zations that receive federal monies toprovide meaningful access, in the formof interpreters and translated materials,to the growing number of individualswho are not proficient in the Englishlanguage (DOJ 2001). Quickly there-after, the U.S. Department of Healthand Human Services's (HHS) Office ofMinority Health developed the NationalStandards for Culturally and Linguistically

Appropriate Services in Health Care—the

first comprehensive and nationally rec-ognized standards to guide healthcareprofessionals in their efforts to provideculturally and linguistically appropriatecare. The 14 standards are grouped intothree themes: (1) culturally competentcare, (2) language access services, and(3) organizational supports for culturalcompetence. Standards related to cultur-ally competent care and organizationalsupports are offered as guidelines. Onlythe standards related to the second

27

JOURNAL OF HEALTHCARE MANAGEMENT 53:1 JANUARY/FEBRUARY 2008

theme—language access services—arerequired by law.

Historically, the foreign-born popu-lation tended to settle in largely diverse,metropolitan areas, such as California,New York, Texas, and Florida. Thehealthcare systems within these stateshave undergone significant changes tomeet the language needs of their for-eign-born communities. Providing forpatients' needs may require that hospi-tals employ various methods to addressand overcome various language and cul-tural barriers. For example, one hospitalin Texas combined having staff inter-preters with placing signs in all patientareas, conducting training sessions forstaff, and employing outside consultants[Obesity, Fitness &> Wellness Week news-letter 2005). An academic institution inWashington, DC, formed a partnershipwith a local clinic to provide servicesspecifically for the Latino commu-nity (Stevenson, Elzey, and Romagoza2002). A health system in Massachusettsprovides patients who are limited-Eng-lish proficient with a variety of languageaccess services, including schedulinginterpreters to be present at appoint-ments, offering translated forms anddocuments, and having staff interpretersfrequently make rounds (Keefe 2005).These and other programs throughoutthe country suggest that numeroushospitals recognize the implications oflanguage and cultural barriers to the ef-fective delivery of patient care.

California, New York, Texas, andFlorida still have the highest percentagesof the foreign-born population. How-ever, states that were previously impervi-ous to a diverse population are sud-denly being introduced to new cultures

and languages (Census Bureau 2003).These states include much of the South:"Across a broad swath of the regionstretching westward from North Caroli-na on the Atlantic seaboard to Arkansasacross the Mississippi River and south toAlabama on the Culf of Mexico, sizeableHispanic populations have emergedsuddenly in communities where Latinoswere a sparse presence just a decade ortwo ago" (Kochhar, Suro, and Tafoya2005, i). Traditionally a biracial region,the South is now home to nearly 30 per-cent of the nation's foreign-born popu-lation (Census Bureau 2004). Koch-har, Suro, and Tafoya (2005) attributethis increase to the region's thrivingeconomy. The growth in industries suchas manufacturing and constructionhas become a magnet for foreign-bornworkers who are seeking employment.Kochhar, Suro, and Tafoya (2005, i) alsostate that while the growth in the overallforeign-born population and in theeconomy "are not unique to the South,[these two factors] are playing out inthat region with a greater intensity andacross a larger variety of communi-ties—rural, small towns, suburbs andbig cities—than any other part of thecountry." Ciamarra (2005) adds that,although the increase in the foreign-born population in Alabama may notbe consistent with the growth witnessedin neighboring states such as Florida,Ceorgia, and Tennessee, "demographicindicators show that the state is headedin that direction."

The shifting migration patterns andthe increase in the foreign-born popula-tion have altered Alabama's demograph-ics; this population has nearly tripledover the last 15 years in that state. Jn

28

CULTURAL AND LINGUISTIC GOMPETENCE IN HEALTHCARE

2005, the Census Bureau estimated that120,773 foreign-born people residein Alabama and that nearly 177,000of residents in the country speak alanguage other than English at home(Census Bureau 2005). This influx ofdifferent cultures and languages maypose a problem for the state's healthcareproviders if they are not equipped tohandle situations that may be culturallyor linguistically sensitive. As the numberof racially, ethnically, and linguisticallydiverse patients continues to increase inthis region, so too does the potential forcostly misunderstandings as a result ofcultural differences or language barriers.To broaden access to and lessen dispari-ties in health and healthcare, therefore,providers must realize the imperative ofproviding services that are culturally andlinguistically appropriate.

METHODOLOGYSampleThis study's units of analysis consistedof general medical and surgical hospi-tals in Alabama (n = 101), These hos-pitals were selected from the AmericanHospital Association's AHA Guide 2005,which lists hospitals under four catego-ries: general, special, rehabilitation andchronic disease, and psychiatric. For thepurpose of this study, only hospitalsregistered as "general" were considered.The AHA Guide (2004, A3) defines"general" as any hospital whose primaryfunction "is to provide patient services,diagnostic and therapeutic, for a varietyof medical conditions." A general hospi-tal may provide additional services suchas diagnostic x-ray; clinical laboratory,including anatomical pathology; andsurgical. Because the AHA Guide only in-

cludes hospitals that are AHA members,the general hospital list obtained fromthe Guide was compared to the AlabamaDepartment of Public Health's ProviderServices Directory to ensure that all gen-eral hospitals in the area were identified.

Hospitals categorized as offeringgeneral medical and surgical servicestotaled 101. The chief executive officers(CEO) of these hospitals were solicitedto participate in the study. Question-naires were mailed to all 101 CEOs,and Dillman's (2000) multiple-contactstrategy was used to reduce nonresponserates—that is, each CEO was contactedthree times: the first questionnaire wasmailed in June 2006, another copy ofthe questionnaire was mailed in July2006, and a reminder was mailed inAugust 2006. Although the question-naires were addressed to CEOs, it is notclear whether the CEO or another staffmember in the organization completedthe survey.

Data and AnalysisWe created a questionnaire that con-sisted of both open- and closed-formatquestions. These questions were de-veloped using the National Standardscreated by the Office of Minority Health(HHS 2001). Through these guidelines,the Office of Minority Health suggests anumber of ways that healthcare provid-ers can address the challenges associatedwith establishing culturally and linguis-tically competent practices. We also usedHHS's (2005) A Patient-Centered Guide

to Jmplementing Language Access Services

in Healthcare Organizations, which servesas a detailed guide for healthcare pro-viders on how to implement languageaccess services.

29

louRNAL OF HEALTHCARE MANAGEMENT 53:1 IANUARY/FEBRUARY 2008

We assessed the application of theNational Standards with the use of nomi-nal-level variables (1 = yes, 0 = no) andordinal-level variables (five-point Likert-like scale, where 1 = strongly agree, 2 =agree, 3 = neither agree nor disagree,4 = disagree, and 5 = strongly disagree).Then, we examined the percentagesfor each variable. The ordinal variablesusing Likert-like scale responses werecollapsed to 1 = agree (includes stronglyagree and agree responses), 3 = neitheragree nor disagree, and 5 = disagree(includes strongly disagree and disagreeresponses). We analyzed the data usingChi-square test statistic to determineif responses differed by ownership,county, bed size, or system membership.

RESULTSSample CharacteristicsTable 1 shows the characteristics of thesample. CEOs from 59 of the 101 hos-pitals responded to the survey, repre-senting 58.4 percent of the total popu-lation of Alabama general hospitals.Questionnaires with missing data wereexcluded from the study, resulting in afinal sample of 53, or 52.5 percent. Thesample included more public hospitals(41.5 percent) than private, nonprofit(32.1 percent), and for-profit (26.4 per-cent) hospitals, and the overwhelmingmajority of the hospitals were locatedin rural counties (69.8 percent). Morethan 49 percent of the hospitals had 100beds or fewer; 47.1 percent had between101 and 500 beds; and 3.8 percent had501 beds or more. Finally, 56.6 percentof the hospitals belonged to a healthsystem.

We compared the mean characteris-tics of this sample to the overall popula-

tion of general hospitals in Alabama,using Chi-square analysis to determineresponse bias (see Table 1). No signifi-cant differences were found in terms ofownership, bed size, or belonging toa health system. However, the sampledid differ in terms of location (urban orrural) from the overall hospital popula-tion in Alabama.

CEO ResponsesFirst, CEOs were asked regarding thegrowth in non-English-speaking or lim-ited-English-speaking patients in theirorganization and whether they believedthat this increase posed future problemsfor their hospital. More than 71 percentof CEOs indicated they had witnessedthis increase within the last year. Re-spondents believed that this growthcould cause future cultural (more than62 percent) and linguistic (more than83 percent) problems.

Next, CEOs were asked to indicatetheir level of agreement or disagree-ment with a series of statements re-lated to the provision of culturally andlinguistically appropriate services attheir hospital; CEOs were also asked torate their hospital's commitment to thedelivery of such services. These findingsare summarized in Table 2. Regard-ing the question about whether or notculturally appropriate care was part of thehospital's mission, the majority of CEOs(56.6 percent) agreed that such care wasincluded in their mission statement.Our Chi-square analysis revealed thatresponses to this question significantlydiffered depending on location: CEOsat rural hospitals were more likely toagree than those at urban hospitals. Asmaller percentage of respondents (41.5

30


TABLE 1Characteristics of Sample

Organizational Characteristics

Ownership

For-profit, proprietary

Private, nonprofit

Public

Location

Urban county

Rural county

Bed Size

100 beds or less

101 to 500 beds

501 beds or more

Health System

Yes

No

•p < .05

Sample (n = 53)Frequency (%)

14 (26.4)

17(32.1)

22 (41.5)

16 (30.2)

37 (69.8)

26 (49.1)

29 (47.1)

2 (3.8)

30 (56.6)

23 (43.4)

^Source: AHA (2004) and Alabama Department of Public Health (2006)

Ail AlabamaGenerai Hospitals^

(n = 101)Frequency (%)

31 (30.7)

32(31.7)

38 (37.6)

41 (40.6)

60 (59.4)

48 (47.5)

49 (48.5)

4 (4.0)

65 (64.4)

36(35.6)

PearsonChi-Square

1.118

5.007*

2.230

2.922

percent) agreed tbat the provision oflinguistically appropriate care was part oftheir hospital's mission.

The majority of CEOs indicated thattheir hospital had written policies andprocedures to ensure the provision ofculturally (58.5 percent) and linguisti-cally (77.4 percent) appropriate services.CEOs of hospitals that were members ofa health system were significantly morelikely to agree to this statement. In spiteof the high agreement, however, only18.9 percent indicated that a specificperson or department had been chargedwith promoting cultural competencewithin their hospital. CEOs of nonprofit

and public hospitals were significantlymore likely to disagree with that state-ment than the respondents from inves-tor-owned hospitals.

Thirty-four percent of the hospitalsmaintained current information on newcultural groups that moved into theirservice area. Hospitals that belonged toa health system were significantly morelikely to maintain such cultural infor-mation than were nonsystem hospitals.Fifty-nine percent of hospitals main-tained current epidemiological profilesof their service area. Public hospitalswere significantly more likely to collectepidemiological information than were

31


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investor-owned and nonprofit hospitals.More than 41 percent of respondentsindicated that their hospital regularlyworked or consulted with their com-munity's cultural, ethnic, and religiousgroups regarding the forms of care andservices that should be made availableto members of those groups. More than66 percent agreed that the cultural de-mographics of their workforce mirroredthose of their service area.

Table 3 presents the findings relatedto the provision of language accessservices. CEOs were asked if they hadtrained interpreters on staff and, if so,for what hours or shifts and in what lan-guages were they available. More than49 percent indicated that they had suchtrained interpreters on staff The mostoften-cited available language was Span-ish, representing 84.6 percent of theresponses. Cerman, Korean, Mandarin,Chinese, and Swahili were also amongthe languages listed by respondents.Respondents who indicated that theirhospital did not have trained interpret-ers on staff were asked to select closed-ended answers that might explain thechallenges in providing this service.Nearly 96 percent cited difficulty in find-ing a trained interpreter in their area.As expected, hospitals that cited thisspecific difficulty were significantly morelikely to be located in rural rather thanurban areas and had smaller (less than100 beds) rather than larger bed capac-ity. Furthermore, 80 percent of respon-dents indicated that non-English-speaking or limited-English-speakingpatients generally brought a familymember or friend to help translate.

Although the CEOs generally ac-knowledged the language challenges fac-

ing their facilities, only 18.9 percent ofrespondents agreed that they gave hiringpreference to bilingual candidates. Ofthese respondents, 70 percent indicatedthey preferred Spanish-speaking candi-dates, and 30 percent did not specify apreferred language. The lack of hiringpreferences did not preclude the CEOsfrom recognizing the need for health-care practitioners to learn a secondlanguage (77.4 percent agreed). Therewas a significant difference betweenthose who agreed (public hospitals)with that statement and those who didnot agree (investor-owned and non-profit hospitals). Interestingly, only 13.2percent offered free foreign-languageclasses (generally Spanish) to interestedemployees. Rural and smaller hospitalswere significantly less likely to offer thisservice than were their urban and largercounterparts. The final workforce-relatedquestion asked if the CEOs considered ita current priority to develop a culturallyand linguistically competent workforce.More than 43 percent agreed that thiswas a priority. However, as with the pre-vious question, rural hospitals viewed aculturally and linguistically competentworkforce as less of a priority than didurban hospitals.

Delving further into the issue oflanguage access, CEOs were asked iftheir hospital subscribed to a telephoneinterpreter service. The overwhelmingmajority of respondents (79.2 percent)indicated that their hospital did sub-scribe. Nonprofit, rural, smaller, andsystem hospitals were all more likely touse telephone interpreter services thanwere their respective counterparts. Re-spondents who did subscribe indicatedthat the service was available 24 hours a

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day. The final question on the question-naire asked if the hospital posted signsin a language other than English. Eighty-three percent of respondents agreed tothis statement. Smaller hospitals (withfewer than 100 beds) were significantlymore likely to post signs in other lan-guages than were larger hospitals.

D I S C U S S I O NThe findings reveal that Alabama gen-eral hospitals were indeed witnessing anincrease in the number of non-English-speaking or limited-English-speakingpatients and were taking the initial stepsnecessary to offer culturally and linguis-tically appropriate services. Many ofthe resources necessary to promote andmonitor these services, however, werenot readily available. As expected, whenthe responses were grouped by organi-zational characteristic, we found signifi-cant differences. Clearly, the challengesrelated to meeting federal guidelinesvaried from hospital to hospital. Thesechallenges were likely driven by notonly the perceptions of the CEOs butalso by resource constraints that facedcertain hospitals.

Approximately one-third of respon-dents agreed that their hospital main-tained current information on culturalgroups that were moving into theirservice area, and less than 40 percent in-dicated that they regularly worked withcultural, ethnic, and religious groupsin their communities to determine theforms of care and services that shouldbe made available to members of thosegroups. The National Standards stressesthe need for healthcare providers to pe-riodically collect information regardingnew cultural groups that move into their

service area. Awareness of these incom-ing groups not only gives hospitals theopportunity to learn about the appro-priate forms of care and services forsuch groups and to subsequently traintheir staff, but it also allows hospitals toensure that these groups are adequatelyrepresented in their workforce andthroughout all levels of the organiza-tion.

Our findings indicate that Alabamahospitals did not have a specific personor department charged with promotingcultural and linguistic competence. TheNational Standards argues that designat-ing a specific person or departmentto develop, implement, and maintaincultural and linguistic competencies en-sures that these competencies are execut-ed throughout the organization and arecontinuously monitored for improve-ment opportunities. "For example, hav-ing qualified interpreters and translatedmaterials available at the time of needis nearly impossible without designatedstaff who are responsible for organiz-ing and dispatching the services" (HHS2001, 84). Not designating a specificperson or department with the responsi-bility of overseeing the implementationand maintenance of these competenciesmay suggest to others in the organiza-tion that the initiatives are not impor-tant. Lack of accountability may alsoresult in poor or improper implementa-tion, training, and evaluation.

To develop a comprehensive strat-egy for the organization, hospitals mayconsider assembling a committee ortask force composed of employees andmanagers from different departmentsand units. This committee can collabo-rate with various departments to devise

35


training programs, clinical protocols,and evaluation processes. Initially, thecommittee can play a more active rolein guiding departments through theimplementation process. Once the newprocesses are employed, the committeecan then simply monitor departmentalprogress and periodically evaluate out-comes and make changes where neces-sary. The committee, however, musthave strong upper-management sup-port for the purposes of legitimacy andlongevity. Raso (2006, 56) argues that"the glue that ties [cultural competence]all together is leadership." It is a trans-formational process that requires leadersto transform their vision and to adopta new paradigm for their organization.Achieving cultural competence requiresa spirit of inclusion and the belief thatdifferences are valuable. Dreachslin(1996) adds that leaders are essential tofostering an environment of acceptanceand understanding. Only when this ac-ceptance and understanding is reachedwill patients benefit from the provisionof culturally appropriate care.

As expected, a large percentage ofCEOs indicated that they did not havetrained interpreters because of the dif-ficulty in finding individuals in the areawho were qualified to serve as interpret-ers. The respondents also indicated thatnon-English-speaking patients generallybrought a family member or friend whocould help translate. These findings raiseserious concerns regarding equity andthe quality of care provided to non-English-speaking patients. Flores (2006,231) argues that "such interpreters areconsiderably more likely than profes-sional interpreters to commit errors thatmay have adverse clinical consequences."

Family members or friends may not befamiliar with certain medical terms orprocedures, and this results in impropertranslation of information. In somecases, the family member or friend maydecide not to worry the patient with acertain test result or the potential sideeffects of a procedure, resulting in alack of true informed consent. A familymember or friend may also be put inan uncomfortable situation by havingto discuss a medical problem that isof a serious or personal nature, result-ing in the lack of privacy. The NationalStandards states that family members orfriends should only be used as trans-lators when the patient specificallyrequests them and refuses the trainedinterpreter provided by the hospital.Family members or friends should notbe relied on as a primary source of inter-pretive services.

A means of combating the prob-lem of finding qualified candidates toserve as trained interpreters may rest inthe National Standards's suggestion thathospitals "grow [their] own" staff. Thismethod consists of hiring individualswho are actively involved in their racial/ethnic communities and training themto act as cultural brokers and interpret-ers. They can serve as a bridge betweenthe hospital and the cultural group,helping newcomers learn about thiscountry's healthcare system and help-ing the hospital learn about the group'scultural values, beliefs, and practices.

Throughout the United States, sev-eral healthcare organizations that serve alarge population of Latinos have suc-cessfully employed health promoters or"promotores de salud" (Migrant HealthPromotion 2005). Under this model.

36


which is similar to the "grow your own"staff model, health promoters work withthe community leaders ofthe culturalgroup to distribute information on whathealth resources are available and howto access those resources, including im-munization and well-baby care. Thesehealthcare workers also promote theadvantages of a healthy lifestyle, provid-ing tips on quitting smoking, exercising,and having regular medical checkups.

The South is now home to 29.2percent of the foreign-born popula-tion in the United States. Subsequently,the number of non-English-speakingor limited-English-speaking patients isrising, as is the likelihood of misunder-standings, medical errors, and feelingsof frustration over patient-provider en-counters. As this segment ofthe popula-tion continues to grow, Alabama generalhospitals will be forced to becomeculturally and linguistically competentto enable them to lessen barriers to ac-cess, obtain adequate information fordiagnostic and treatment purposes, andprovide high-quality care to all patients.The need for hospitals to develop aculturally competent workforce and tomake interpretive services available willintensify as hospitals struggle to provideappropriate and equitable care in a cost-effective manner.

LimitationsAs a descriptive project, this study hasseveral limitations. Eirst, the sample wasrestricted to only general medical andsurgical hospitals in one state. The find-ings, therefore, cannot be generalizedto all the states but may be suggestivefor states that are culturally and demo-graphically similar to Alabama. Another

factor that affects the study's generaliz-ability is the sample size. Even thoughthe number of usable surveys repre-sented slightly more than 50 percent ofthe population, we acknowledge thatthe results reflect the perceptions and ac-tions of only 53 hospitals. Nonetheless,we still believe that the perceptions andactions of these CEOs are pertinent toour understanding ofthe challenges thatface hospitals in areas that are undergo-ing population changes. The perspec-tives of the CEOs in this study may berepresentative of CEOs in other statesthat are also undergoing similar demo-graphic changes.

Second, the questionnaire was ad-dressed to the hospitals' CEOs; however,as noted earlier, it is not clear who,within these hospitals, completed thesurvey. Civen the nature of the ques-tions, and if the CEO did not answer thesurvey, someone with sufficient and ac-curate organizational knowledge equiva-lent to that ofthe CEO was the likelyrespondent. Third, the study lacked acausal model. The purpose ofthe studywas merely to describe the perceptionsand activities of CEOs in Alabama hos-pitals. Therefore, no conclusions weredrawn regarding the factors that influ-enced CEO behavior or actions.

Finally, no pre-testing of the surveyinstrument was performed. Althoughpre-testing is certainly the best way totest our questionnaire, the underlyinggoal of this project was to determine thealignment of hospitals with current fed-eral guidelines on cultural and linguisticcompetencies. Therefore, the questionswere developed using the language fromthe National Standards.

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P R A C T I T I O N E R A P P L I C A T I O

Alison Walker, senior vice president, planning. Our Lady of the Lake RegionalMedical Center, Baton Rouge, Louisiana; Coletta C. Barrett, RN, vice president of

mission services. Our Lady of the Lake Regional Medical Center; andAlice Battista, RN, director of mission services. Our Lady of the Lake Regional

Medical Center

W hen we were asked by the authors to review this article, we questioned therelevance of the experiences of Alabama hospitals to Louisiana hospitals. After

reviewing and discussing the findings in this article, however, we have a deeper ap-preciation for the potential "take aways" of this study and its implications for Louisi-ana and other hospitals.

This article is a quick read, well organized, and well written. It makes a cleardistinction between being linguistically competent (through provision and use ofinterpretive services) and being culturally aware (through full transparency of ethicaland moral decisions). The use of interpretive services, such as the AT&T interpreta-tion line, meets the linguistic needs of an institution. However, the organization'sgoal to meet patients' cultural needs is more difficult to accomplish, requiring a pro-active commitment and a deeper understanding of cultural competence issues. Thisarticle provides examples of cultural programs and processes that are both feasibleand replicable.

The study surveyed CEOs of acute care hospitals in Alabama. The findings indi-cate that responding CEOs were aware of cultural and linguistic issues in their respec-tive organizations. They also recognized that complex solutions were needed to moreappropriately prepare their institutions and workforce and that quick fixes in accessto linguistic services do not address the matter of cultural sensitivity in healthcaredelivery. Leaders at our institution recognize this truth as well.

By completing a baseline assessment, your institution's awareness of the issuessurrounding competence is increased. For example, as a result of reviewing thisarticle, we incorporated cultural and linguistic competency elements into our qualityand performance improvement plan as well as into our human resources recruitmentand development plan. Our initial steps involved reassessing our community popu-lation to identify changing demographics and reviewing our workforce to evaluateany shift. After Hurricane Katrina, the demographics of Baton Rouge shifted, signal-ing a need for us to add questions to our employment application process to betteridentify bilingual applicants.

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The article's recommendation to include community representation (connectiv-ity with the community) to ensure a culturally diverse community advisory groupintrigued us. Although our institution has not yet considered this concept, we havesupported an internal diversity committee for more than five years and have donemuch to address cultural competency among our staff. One tool that our institutionhas used to address personal bias in culturally sensitive situations is our Dialogueson Racism Program. This six-week program brings staff together once a week for afacilitated discussion on tolerance. The participants discuss how racism becomesinstitutionalized and perpetuated in organizations and explore ways to open com-munication and address bias. At our facility, the CEO, COO, members of the seniormanagement team, and leadership staff have all participated in the program.

The article did not address the medical staff—a key constituent of any healthcareinstitution. Including and engaging this influential clinical group in cultural andlinguistic programs is imperative. The article indirectly raises the issue of providingcare to illegal immigrants, as opposed to documented foreign-born citizens. Whena small number of undocumented people are present in a community, we recognizetheir uniqueness. But when that number rises to a critical mass, the dynamics at playwarrant a change in the system and challenge our response to this cultural issue. Theissue then is viewed as problematic rather than met with sympathetic consideration.Civen the current political debate about naturalization of illegal immigrants, it be-comes even more paramount for institutions to know their community's cultural andlinguistic needs sooner rather than later.

As we continue our journey to identify programs, processes, and solutions toaddress cultural, ethnic, and religious differences among those who give and receivehealthcare in our facilities, this article provides a guideline. It renders an opportunityfor self-assessment so that we can be more aware of avenues for improvement, and itprovides practical suggestions for implementing an extensive host of recommenda-tions.

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