Leadership

1. Create and sustain an environment of cultural competency through establishing leadership structures and systems or embedding them into existing structures and systems.
2. Identify and develop informed and committed champions of cultural competency throughout the organization in order to focus efforts around providing culturally competent care.
3. Ensure that a commitment to culturally competent care is reflected in the vision, goals, and mission of the organization, and couple this with an actionable plan.
4. Implement strategies to recruit, retain, and promote at all levels of the organization a diverse leadership that reflects the demographic characteristics of the service area.
5. Ensure that the necessary fiscal and human resources, tools, skills, and knowledge to support and improve culturally competent policies and practices in the organization are available.
6. Commit to cultural competency through system-wide approaches that are articulated through written policies, practices, procedures, and programs.
7. Actively seek strategies to improve the knowledge and skills that are needed to address cultural competency in the organization.
   
   

Patient-Provider Communication

1. Implement language access planning in any area where care is delivered.
2. Offer and provide language access resources in the patient’s primary written and spoken language at no cost, at all points of contact, and in a timely manner during all hours of operation, and provide both verbal offers and written notices informing patients of their right to receive language assistance services free of charge.
3. Determine and document the linguistic needs of a patient or legal guardian at first points of contact, and periodically assess them throughout the health care experience.
4. Maintain sufficient resources for communicating with patients in their primary written and spoken languages through qualified/competent interpreter resources, such as competent bilingual or multilingual staff, staff interpreters, contracted interpreters from outside agencies, remote interpreting services, credentialed volunteers, and others, to ensure timely and high-quality communication.
5. Translate all vital documents, at a minimum, into the identified threshold languages for the community that is eligible to be served.
6. Translate written materials that are not considered vital when it is determined that a printed translation is needed for effective communication.
7. Ensure that a qualified interpreter reads a document to a patient if the patient cannot read the translated document.
8. Use “teach back” as a patient engagement tool to enhance communication between the health care provider and the patient during clinical encounters.
9. Communicate key information about the proposed treatments or procedures for which patients are being asked to provide informed consent.
10. Include family members in health care decisions, when requested by the patient, when providing care for culturally diverse populations.
    
    

Care Delivery and Supportive Mechanisms

1. If requested by the patient, provide resources such as provider directories that indicate the languages providers speak, so that patients can have access to this information.
2. Develop and implement a comprehensive care plan that addresses cultural concerns.
3. Consider cultural, spiritual and religious beliefs that may complement or conflict with standard medical care.
4. Adapt the physical environment where the health care is being delivered to represent the culture of the populations who access their health care in that environment.
5. Use culturally appropriate care coordination services that take into consideration the cultural diversity of the populations seeking health care.
6. Explore, evaluate and consider the use of multimedia approaches and health information technology to enable the provision of health care services that are patient and family centered.
   
   

Workforce Diversity and Inclusion

1. Recruit and hire ethnically diverse providers and staff at all levels. Actively promote the retention of a culturally diverse workforce through organizational policies and programs.
2. Assure availability of a trustworthy process for the expression of employee grievances and concerns regarding race, ethnicity, language and other diverse characteristics that protects the integrity and confidentiality of employees.
3. Implement reward and recognition programs to recognize specific individuals, initiatives and programs within the organization that promote cultural competency.
   
   

Education and Training

1. Implement education and training that builds a workforce that is able to address the cultural needs of patients and provide appropriate and effective services as required by federal, state and local laws, regulations and organizational policies.
2. Integrate cultural knowledge and processes of culturally appropriate care into residency, fellowship and medical student curricula, partnering with learners’ home educational institutions as appropriate.
3. Connect workforce to education and training opportunities outside of the organization that may enhance their cultural competence abilities.
4. Regularly assess attitudes, practices, policies and structures of all staff as a necessary, effective and systematic way to plan for and incorporate cultural competency within an organization.
   
   

Data Collection, Public Accountability, and Quality Improvement

1. Ensure that, at a minimum, data on an individual patient’s race and ethnicity (utilizing national standards and best practice evidence) and primary written and spoken language are collected in health records and integrated into the organization’s management information systems. Periodically update the language information.
2. Maintain a current demographic, cultural and epidemiological profile of the community to accurately plan for and implement services that respond to the cultural characteristics of the service area.
3. Apply a quality improvement framework to improve cultural competency and discover and eliminate disparities in care using the race, ethnicity and primary written and spoken language information collected by the institution.
4. Publicly report data for the applicable NQF-endorsed disparities-sensitive national voluntary consensus standards for ambulatory care stratified by race/ethnicity and primary written and spoken language.
5. Regularly make available to the public information about progress and successful innovations in implementing culturally competent programs and provide public notice in communities about the availability of this information.
6. Assess and improve patient- and family-centered communication on an ongoing basis.
7. Any surveys created by or conducted by the organization must collect race, ethnicity and primary written and spoken language, and analysis and results must be stratified by race, ethnicity and primary written and spoken language.
8. Ensure that conflict and grievance resolution processes are culturally sensitive and capable of identifying, preventing and promptly and equitably resolving cross-cultural conflicts or complaints by patients or between organizational staff.

Adaptation of National Quality Forum (NQF). A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency: A Consensus Report. Washington, DC: NQF; 2009.