Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education:
The Role of the HRSA Centers of Excellence

Executive Summary

Ensuring cultural and linguistic competency among health care professionals is a critical issue that the U.S. health care system must address in order that all individuals residing in the United States, regardless of race, ethnicity, gender, age, language, country of origin, sexual orientation, religion/spirituality, socioeconomic class, political orientation, educational/intellectual levels, and physical/mental ability have access to and receive quality health care. Cultural and linguistic competency is not an adjunct to, but a core component of quality health care. The focus on cultural and linguistic competency in this curriculum guide is based on the understanding that all organizations and individuals operate within cultural frameworks, and that health care providers have an obligation to respectfully consider these cultural frameworks when they are designing and delivering health care services. The training of health care professionals should provide the skills and knowledge that will allow health care practitioners to incorporate cultural and linguistic competency into the standard practice of each particular discipline.

In 1991, the Health Resources Services Administration (HRSA) of the Federal Department of Health and Human Services created the Centers of Excellence (COE) Program. The program was designed to support excellence in health professional education for underrepresented minorities (URM) in health professional schools of medicine, dentistry, pharmacy, and mental health (Note: Nursing and allied health professional schools are not included in the HRSA COE Program but may still find this curriculum guide useful in developing cultural and linguistic competency in their institutions).

HRSA COEs differ from other Centers of Excellence programs (such as Women’s COEs) in that they focus primarily on racially and ethnically underrepresented minorities in health professional programs. As a program intended to reduce disparity in the health care system by increasing the number of URMs in the health field, the HRSA COE program was one of the earliest programs to mandate the teaching of cultural and linguistic competency content in the educational curricula among HRSA grant recipients. Section 736 of the Health Professions Education Partnerships Act of 1998 encourages COEs “… to carry out activities to improve the information, resources, clinical education, curricula and cultural competence of the graduates of the schools as it relates to minority health issues.” Although the COE Program encompasses many goals, the incorporation of cultural and linguistic competence training was visionary for its time.

This curriculum guide, Transforming the Face of Health Professions through Cultural and Linguistic Competence: The Role of the Centers of Excellence, was developed by a panel of experts, the Expert Team, brought together under a contract awarded by HRSA to Magna Systems, Inc. The extensive materials and recommendations contained in the document are intended to assist the COEs in designing and implementing the required cultural and linguistic competency educational components within their specific disciplinary curricula. The materials are appropriate for training health care professionals in medicine, dentistry, pharmacy, social work, psychology and counseling, and allied fields.

The Expert Team was drawn from the fields of medicine, nursing, pharmacy, psychology, anthropology, organizational development, and hospital administration. Collectively, the team members have significant and long-term knowledge and experience in the field of cultural and linguistic competency. Additionally, each Expert Team member has extensive experience in teaching cultural and linguistic competence subject matter to health care professionals.

Over 18 months, this team collaborated in collecting, reviewing, and organizing the resources in this curriculum guide under the supervision and direction of the HRSA’s Division of Health Careers Diversity and Development, Bureau of Health Professions.

In developing the curriculum guide, the Expert Team drew considerably on feedback from COEs. Several opportunities were identified to initiate and maintain dialogue with them. The first opportunity occurred on March 19, 2004, at the annual COE grantees meeting in Washington, D.C. Two focus groups, led by Dr. Maria Soto-Greene and Mr. Beau Stubblefield-Tave, shared information regarding the project and gathered input from the COE grantees. The second opportunity to meet with COE grantees in a formal meeting was on October 6, 2004, in Washington, D.C., at the COE National technical assistance meeting. Electronic and paper copies of the draft curriculum guide were distributed to the COE grantees prior to this meeting. The input provided by the COE representatives was extremely useful and helped refine the curriculum guide. Magna Systems Inc., in collaboration with the Expert Team, also conducted a comprehensive assessment of the cultural competence activities of COE grantees and catalogued “best practices” for teaching cultural competency in health professions schools. The Assessment and Promising Practices Report documents these findings (see Appendix C).

When developing the material for this curricular guide, the expert team adopted the following premises:

• Health care providers have an obligation to respectfully consider cultural concerns as they design and deliver health care services. While it is not possible for any individual to become thoroughly familiar with the myriad cultures that exist within the United States, providers and the institutions that train them can and must incorporate the general principles of cultural and linguistic competency into the standard practice of care.
  
• The curriculum guide is being made available to COE grantees as a generic model for use in guiding the planning, development, implementation, and evaluation of cultural and linguistic competency education activities with faculty and students. The curricular materials can be used to supplement work already being done in many COEs, and are not mandatory or intended to replace existing or planned cultural and linguistic competency activities.
  
• The curricular materials focus on generic concepts and skills that the expert teams considered to be important. The materials are not designed to address the varying levels of cultural and linguistic competence education that may already be present in different COEs.
  
• The Expert Team identified certain approaches and models through collective consensus. However, these are by no means the only ones available. Readers will find alternative approaches in Chapter 10 (Resources) and in the appendices.
  
• Since COEs do not have a specific mandate to ensure the cultural and linguistic competency of the larger institutions of which they are a part, the primary users of this document will be COE faculty and other COE academicians; COE students are intended to be its primary beneficiaries. It is necessary and important, however, to acknowledge the significant link between an organization’s cultural and linguistic competence and its implementation of successful cultural and linguistic competence education. Recognizing this link, the Expert Team strongly supports a leadership role for COEs in advocating cultural and linguistic competence in the larger university communities in which they reside. Wherever possible, COEs should encourage collaborative arrangements around cultural and linguistic competency subject matter with other university departments.
  
• Since HRSA COEs were among the earliest programs to require a cultural and linguistic competency mandate, many COE directors expressed the need for guidance on change processes and gathering support for the concept in a larger institution. Therefore, although it may not have a direct link to curriculum development, it may be beneficial for the COEs to receive information on organizational change and innovation from fields outside of health care (contained in Chapter 3).

Given these facts, the Expert Team encourages all users of this curriculum guide, Transforming the Face of Health Professions Through Cultural and Linguistic Competence Education: The Role of HRSA Centers of Excellence, to consider it an evolving document. The Expert Team invites all users to join with its developers in the practice of “cultural humility” (Tervalon and Murray-Garcia, 1998) as we assess the value of its content and seek to use it to promote the delivery of culturally competent health care. Users of this curriculum guide are urged to engage in participatory and collaborative processes and to share the lessons they learn freely. While the information in this curriculum guide is designed primarily for use by COEs, it may also be a useful guide and resource for other institutions and organizations that provide education and training to health care providers. The members of the Expert Team hope that the strategies and resources provided here will be disseminated appropriately and used by relevant organizations.

Organization of the Curriculum Guide

This compendium provides practical guidance in the form of strategies, tools, and resources for COEs implementing and integrating cultural and linguistic competency content and methods into existing academic programs. It also provides guidance for evaluating cultural and linguistic competency efforts. The curriculum is organized into 10 chapters. An overview of the content of these chapters follows:

Chapter 1: Cultural and Linguistic Competence and the Centers of Excellence provides an overview of the COE legislative mandates, a brief history of COE cultural and linguistic competency initiatives, and the preliminary findings of an assessment of past and current COE cultural and linguistic competency activities.

Chapter 2: The Guiding Principles and Goals of Cultural and Linguistic Competence Education presents guiding principles and goals designed to help COEs maintain a clear and constructive focus on cultural and linguistic competency as they negotiate the complexities of planning, designing, implementing, and evaluating cultural and linguistic competence training and education programs into existing curricula.

Chapter3: Strategies for Success in Implementing Cultural and Linguistic Competence Education outlines the rationale for educating for cultural and linguistic competence and provides an overview of the change management process. It also examines cultural and linguistic competence at the organizational level, including an overview of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (the CLAS Standards).

Chapter 4: Creating a Framework for Cultural and Linguistic Competence Curriculum discusses some of the methods of teaching cultural and linguistic competency and of designing, modifying, and delivering cultural and linguistic competency curricula. Specifically, the topics covered in this chapter are the dimensions of multicultural education when designing and modifying curricula, incorporating the process of cultural competence in the delivery of health care services model, and adhering to standard principles of instructional systems development (ISD).

Chapter 5: Curriculum Content for Cultural and Linguistic Competence provides guidance and recommendations on content areas that could be included in a cultural and linguistic competency curriculum and discusses curricula models that are being used in various educational settings to teach cultural and linguistic competence. The topics covered in this chapter include learning objectives, recommended core competencies, recommended core curriculum topics, and examples of curriculum models. The last section includes three models used in curriculum development.

Chapter 6: Delivering a Cultural and Linguistic Competence Curriculum describes the processes and strategies that are used for delivering cultural and linguistic competence curricula and also provides examples of how several organizations have implemented components of culturally competent curricula. Included is a discussion about developing faculty commitment, providing a rationale for building cultural and linguistic professional competencies, creating a developmental learning path, integrating cultural and linguistic subject matter into basic and elective courses, and sample tools for delivering cultural and linguistic curricula.

Chapter 7: Assessment and Evaluation of a Culturally Competent Center of Excellence describes how COEs can make an initial assessment or benchmark of their cultural and linguistic competency training and education activities and then continuously assess organizational and educational programming. This chapter includes a discussion on educational assessments and evaluations, three examples of curriculum evaluation, organizational assessments and evaluations, the HRSA domains as a framework for organizational assessment, and integrated and stand alone evaluation processes.

Chapter 8: Dissemination outlines the process for developing a dissemination plan to share the lessons learned about the delivery of culturally competent health care in the community. It describes the importance of getting support from key stakeholders, such as university administrators and faculty, and strategies for achieving the adoption and integration of cultural and linguistic competency into established and new courses of study. It discusses the reasons a COE would disseminate, the mechanisms for dissemination, and offers examples of an effective dissemination plan.

Chapter 9: Summary/Next Steps discusses some caveats, potential issues, challenges, and barriers to the use of the curriculum guide. It also summarizes the important recommendations of the curriculum guide and provides suggestions for implementation.

Chapter 10: Resources is a list of cultural and linguistic competency guidelines, curricula, research reports, organizations, audio-visual tools, and web sites that may be helpful to COEs in their efforts to respond to their cultural and linguistic competency mandate.

Appendix A: The Toolbox, provides examples of tools and implementation strategies developed for teaching cultural and linguistic competency in health care.

Appendix B is a glossary of terms related to cultural and linguistic competency education.

Appendix C contains the Centers of Excellence Assessment and Promising Practices Report that describes cultural and linguistic competence activities of HRSA COE grantees.