NationalStandards

National Standards for Culturally and Linguistically Appropriate Services in Health Care

The National CLAS Standards are intended to advance health equity, improve quality, and eliminate health care disparities by establishing a blueprint for health and health care organizations.

In the late 1990s, the U.S. government became seriously concerned with the health conditions of the nation’s increasingly diverse communities. Margaret Heckler, former Secretary to the U.S. Department of Health and Human Services (USDHHS), headed a task force charged with addressing this challenging issue and finding urgent solutions. After an extensive investigation and study of existing cultural and linguistic competence standards and measures, it became clear that the quality of health care services patients from low-income backgrounds were receiving was very poor, especially among minorities (African Americans and Latinos, in particular).

As a result, the USDHHS developed an initial set of 15 health care standards to address these disparities. The first draft was presented for discussion to health institutions at three regional meetings in San Francisco, Baltimore, and Chicago. Approximately 413 health institutions and organizations reviewed this initial draft and provided feedback.1

The findings of this study confirmed that health disparities and iniquities in the U.S. were pervasive. To address this issue, recommendations were made for the provision and application of culturally and linguistically appropriate health services through the use of standards. It was determined that offering services that are respectful of and responsive to the cultural health beliefs, practices, and needs of diverse patients could help close the gap in health care outcomes and lead to more positive results. Heckler asserted that the pursuit of health equity must remain at the forefront of efforts by health care professionals. She urged health care professionals to remember that dignity and quality health care are the rights of all and not of a privileged few.

In December 2000, the Office of Minority Health (OMH) at the USDHHS published the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards).2 These standards have since provided the framework for all health care organizations to best serve the nation’s increasingly diverse communities.

What Are CLAS Standards?

The National CLAS Standards are a collective set of mandates, guidelines, and recommendations intended to inform, guide, and facilitate required and recommended practices related to culturally and linguistically appropriate health services. Although adherence to these standards is voluntary, many health organizations have committed to following some or all of the 15 standards. The standards fall under three themes:

Governance, Leadership, and Workforce: This emphasizes that the responsibility of implementing the standards rests at the highest levels of leadership at an organization.

Communication and Language Assistance: Recommends that free language assistance should be provided as needed in a manner appropriate to the organization’s size, scope, and mission. Health care organizations and providers that receive federal financial assistance without providing free language assistance services could be in violation of Title VI of the Civil Rights Act of 1964.

Engagement, Continuous Improvement, and Accountability: Underscores the importance of quality improvement, community engagement, and evaluation.

Key Elements

To ensure the proper implementation of CLAS Standards, it’s of critical importance for health care professionals and health care organizations to have a clear understanding of cultural competence and linguistic competence.

  • Culture represents the vast structure of behaviors, ideas, attitudes, values, habits, beliefs, customs, language, rituals, ceremonies, and practices of a particular group of people.
  • Competence is an individual’s ability to interact with others in a manner that does not disrespect, demean, or otherwise diminish their group, heritage, traditions, and beliefs.
  • Linguistic competence is 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 illiterate, and individuals with disabilities.

To assist health practitioners to become culturally competent, the following six basic steps are included in the CLAS Standards:

Step 1: Recognize and accept that all types of cultures have a profound influence on our lives.

Step 2: Be aware that oppression is pervasive in our society; that it is part of our history and affects our relationships.

Step 3: Understand that cultural differences exist and learn to accept and respect what we may not always understand.

Step 4: Accept that we cannot know everything about other cultures, and never will.

Step 5: Commit to pursue what we need to know about the groups/patients we serve and those with whom we work in every way available to us.

Step 6: Identify and confront personal resistance, anger, and especially fear, as we seek to gain insight and knowledge about a particular culture or group.

Action Plan for Cultural Competence

One of the most helpful resources that I’ve found to assist health practitioners in developing cultural competency skills was created by Gloria Kersey-Mauriac, a professor of nursing at Holy Family University in Philadelphia and the coordinator for diversity and chair of the university’s Diversity Team.3 She suggests asking the following questions:

  • How much do I value becoming culturally competent?
  • How much do I know about my own cultural heritage or racial identity and its relationship to my own health care belief and practices?
  • How much do I know about cultural groups that differ from my own?
  • How culturally diverse is my social network?
  • Am I able to independently identify potential or actual problems that originate from cultural conflicts?
  • Have I developed problem-solving strategies to manage cultural conflicts?

Aside from these questions, health practitioners also need to keep in mind that culture determines the way patients process (e.g., coping skills) and present information about their illness/condition. Because cultures are so diversified and changing constantly, the best way for a health professional to be competent and sensitive is to be honest (show professional humility) about his or her own lack of knowledge of the backgrounds, beliefs, and values represented by clients/patients. This attitude will offer immediate empowerment to those a provider is trying to assist. It tells the patient, “I acknowledge you as an individual. If I value you enough, then I want you to teach me the best way to communicate with you and your family to meet your health requirements.”

The successful implementation of the National CLAS Standards also requires health care organizations and providers to have a thorough understanding of the communities they serve. This could be done through the implementation of cultural mapping, a valuable tool for investigating and creating a profile of a particular community/culture. This type of mapping encompasses a wide range of techniques and activities, from community-based participatory data collection and management to sophisticated mapping using geographic information systems. Cultural mapping will help facilitate the development of appropriate health care programs and services. For instance, it will reveal the health, nutrition, and communicable diseases prevalent in each target population served by a hospital. It will indicate the values and belief systems for each culture served. In addition, health care professionals will also learn how these values and belief systems are linked to the services they seek to provide (e.g., mental health, oral health, drug and alcohol abuse rehabilitation). Cultural mapping will also demonstrate the range of holistic traditional practices used by a particular community.

Continuing to Evolve

In 2013, the USDHHS Office of Minority Health (OMH) released the enhanced National CLAS Standards. These revised standards provide a framework for organizations seeking to offer services that are responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs.4 Building on the original standards released in 2000, the revised standards employ broader definitions of culture (e.g., beyond traditional considerations of race and ethnicity) and health (e.g., including mental health and physical health). They apply to organizations focused on prevention as well as to health care organizations. To guide and encourage adoption, the Office of Minority Health released a blueprint highlighting promising practices and exemplary programs.5

With this enhanced initiative, the National CLAS Standards will continue into the next decade as the cornerstone for advancing health equity through culturally and linguistically appropriate health services. To learn more about implementing the National CLAS Standards within your organization, visit the Office of Minority Health at http://bit.ly/OMH-CLAS.

Notes
  1. National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report (U.S. Department of Health and Human Services, Office of Minority Health, 2001), 1, http://bit.ly/national-standards-report.
  2. Ibid.
  3. Kersey-Matusiak, Gloria. “Delivering Culturally Competent Nursing Care,” http://bit.ly/Kersey-Matusiak.
  4. Kohn, Howard K., J. Nadine Garcia, and Mayra E. Alvarez. “Culturally and Linguistically Appropriate Services: Advancing Health with CLAS,” New England Journal of Medicine (July 17, 2014), 198–201.
  5. National Standards for CLAS in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice (U.S. Department of Health and Human Services, 2013), http://bit.ly/CLAS-blueprint.

José T. Carneiro has more than 25 years of international senior management and consultant experience in the management and implementation of public health and community development programs in Africa, Europe, the U.S., and South America. As a consultant, he has provided technical assistance to foreign governments, institutions, and community-based organizations on child survival issues, health manpower development, community and institutional strengthening, project sustainability, decentralization, and social marketing. He has also been involved in the design and delivery of training for culturally and linguistically appropriate health services. He has doctor of education from Boston University and a master of public administration from the University of Southern California. Contact: Jtcarneiro24@gmail.com.

Additional Resources:

National Partnership for Action to End  Health Disparities Office of Minority Health
www.minorityhealth.hhs.gov

A Patient-Centered Guide to Implementing Language Access Services in Health Care Organizations (U.S. Department of Health and Human Services, Office of Minority Health, 2005), 243,
http://bit.ly/patient-centered-guide.

Goode, T.D.; M.C. Dunne; and S.M. Bronchium. The Evidence Base for Cultural and Linguistic Competency in Health Care (The Commonwealth Fund, 2006), 46.

Kosoko-Lasaki, Sade, Cynthia Cook, and Richard O’Brien. Cultural Proficiency in Addressing Health Disparities (Jones and Bartlett Publishers, 2009), 433.

Tseng, W.S., and J. Sterilizer. Cultural Competence in Health Care (New York: Springer, 2008), 138.

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