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Cultural Competence and Patient Safety

December 27, 2019 
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Culture can be defined as the “personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions that are often specific to ethnic, racial, religious, geographic, or social groups.”[1]For both patients and providers, healthcare is defined through a cultural lens.[2]An individual’s cultural affiliations can affect where and how they seek care, how they describe symptoms, how they select treatment options, and whether they follow care recommendations.[2] Similarly, providers bring their own cultural orientations, including the culture of medicine.

Cultural competence in healthcare refers to the “ability of systems to provide care to patients with diverse values, beliefs and behaviors, including the tailoring of healthcare delivery to meet patients’ social, cultural and linguistic needs.”[3] Being a culturally competent health system requires behaviors, attitudes, and policies that support effective interactions in cross-cultural situations.[4]

Many models of cultural competence have been developed and these inform a collection of cultural competence interventions, such as provider training and practical tools. While the term cultural competence has predominantly referred to the culture and language of racial and ethnic minority groups, it is increasing being used to encompass other groups, such as people with disabilities and the LGBTQ community among other groups. These populations have been the primary subjects of studies of cultural competence interventions.[5] Cultural competence has also become linked with health literacy, an acknowledgement that mutual understanding between patients and providers calls for the integration of culturally and linguistically competent and health literate approaches.[2] This broadening of cultural competence is reflected in the updated National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care.

The cultural competence movement has grown with the rise of national attention to pervasive racial and ethnic disparities in healthcare.[6] Research has consistently demonstrated health and healthcare disparities between minority and majority populations.[7],[8],[9],[10] The demographic shifts that have created several minority-majority states and diversity in areas that were once homogenous have bolstered the case for cultural competence in healthcare.

Cultural Competence and Patient Safety

Disparities in healthcare extend to the patient safety arena. For example, a study that looked at hospitals across the country found that patients with limited English proficiency were more likely to be harmed than their English-proficient counterparts when they experienced adverse events, and that harm was more likely to be severe.[11] These findings extend to pediatric populations, such as the study that found that hospitalized Latino children are more likely to experience an adverse event than non-Latino white children.[12]

Patient safety events that can result from the failure to address culture, language, and health literacy include diagnostics errors, missed screenings, unexpected negative responses to medication, harmful treatment interactions from simultaneous use of traditional medicines, healthcare-associated infections, adverse birth outcomes, inappropriate care transitions, and inadequate patient adherence to provider recommendations and follow-up visits.[7] For example, lack of understanding that a hospitalized Asian woman would only communicate when a male family member was present, led to a delay in obtaining consent for a necessary surgery.[13] With growing diversity in patient populations across the country, the risk increases that differences between patients and providers will contribute to missed care opportunities and safety events.[7],[14]

In addition to affecting medical errors and harms directly, cultural competence can have a powerful effect on another driver of patient safety outcomes – patient engagement. Cultural and linguistic competence strategies, such as provision of language assistance and the use of cultural brokers, can promote effective communication with diverse patients that is critical to engage them as collaborative partners in their care. Other interventions, such as cultural competence training, can increase understanding of what the patient is experiencing and give providers skills to bridge cultural differences and foster increased trust.[15]

Approaches to Improving Cultural Competence

Provider cultural competence has the potential to decrease patient safety disparities.

Language Assistance

Language assistance, a strategy to overcome language barriers, can take the form of bilingual clinicians and staff and qualified foreign language and American Sign Language interpreters.[16] Successful language assistance relies on the adequacy of the supply of interpreter services, policies on using them, and training on how to access and work with interpreters. Otherwise providers might try to “get by” with the limited English skills of patients, their own inadequate foreign language skills, or unqualified interpreters, such as patients’ friends or family members or untrained staff.[17] Examples of documented patient safety events due to a lack of timely language assistance include performing an x-ray on the wrong part of the body, falls due to the patient not knowing to ask for assistance, and inability to treat emergency room patients due to failure to obtain medical history or medication list.[17]

Cultural Brokers

Using a cultural broker is one potential strategy to enhance cultural competence in healthcare. Cultural brokerage is the mediation between the traditional health beliefs and practices of a patient’s culture and the healthcare system.[18],[19] Interpreters, community health workers, and patient navigators can play the role of a cultural broker by providing context and by serving as a partner for both the patient and provider. While the role of the cultural broker can vary depending on patient and provider need, cultural brokers must be knowledgeable about the cultural group they serve and be able to successfully navigate the healthcare system. An individual acting as a cultural broker should be a trusted and respected member of the community but does not need to be healthcare professionals.[19] Incorporation of a cultural broker in the care team embraces the importance of cultural distinctions among patient groups. It also acknowledges that, particularly in very diverse communities, it is unrealistic for providers to have sufficient understanding of all of the different cultures present in the patient population they serve.

Cultural Competence Training

Cultural competence training programs aim to increase cultural awareness, knowledge, and skills, leading to behavior change.[20] Most reviews of cultural competence training conclude that training has positive impacts on provider outcomes, but as a standalone strategy training may insufficient to improve patient outcomes without concurrent systemic and organizational changes.[21]

AHRQ Project Spotlight – Re-Engineered Discharge (RED) Toolkit

Researchers at the Boston University Medical Center (BUMC) developed a set of 12 actions that hospitals should take during and after the patient stay to improve their discharge process. The most recent iteration of the RED Toolkit includes implementation guidance for delivering the RED to patients with diverse culture, language, race, ethnicity, literacy, sexual orientation, gender identity, etc. It also provides recommendations such as hiring bilingual, bicultural discharge educators, providing cultural and linguistic competence training, and ensuring availability of interpreter services. Further, the toolkit highlights how implementation of each RED component may need to be modified for diverse patient populations.[22] Links to publically available tools and resources that may assist with implementation are provided throughout the toolkit. Research has shown that the RED is effective at reducing readmissions and post-hospital emergency department visits.[23] 

AHRQ Project Spotlight –TeamSTEPPS Limited English Proficiency Module

The AHRQ TeamSTEPPS Limited English Proficiency module is designed to provide hospitals with the tools to develop and implement a plan to train interpreter and clinical staff in teamwork skills, specifically within the context of working with patients with limited English. The module includes train-the-trainer resources and instructional guides that include short case studies and videos.[24] The success of TeamSTEPPS is well documented in the literature[25] and field testing of the LEP module concluded it was easy to implement and fostered staff learning.[26] In addition to implementing the TeamSTEPPS LEP module, the AHRQ guide Improving Patient Safety Systems for Limited-English-Proficient (LEP) Patients, recommends hospitals: 1) foster a supportive culture for safety of diverse patients, 2) adapt current systems to better identify medical errors among patients with LEP, 3) improve reporting of medical errors for LEP patients, 4) routinely monitor patient safety for LEP patients, and 5) address root causes to prevent medical errors among LEP patients.[27]

Cindy Brach, MPP
Senior Healthcare Researcher
Agency for Healthcare Research and Quality
Rockville, MD

Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health
IMPAQ International
Columbia, MD

Eleanor Fitall, MPH
Research Associate, IMPAQ Health
IMPAQ International
Washington, DC


[1] Cultural Respect. Updated February 15, 2017. Accessed December 5, 2019.  

[2] Andruilis DP, Brach C. Integrating literacy, culture, and language to improve health care quality for diverse populations. Am J Health Behav.2007;31 Suppl 1:S122-33.

[3] Becoming a Culturally Competent Health Care Organization. Accessed December 5, 2019.

[4] Brach C, Fraser I. Reducing disparities through culturally competent health care: An analysis of the business case. Qual Manag Health Care. 2002;10(4):15-28.

[5] Butler M, McCreedy E, Schwer N. et al. Improving Cultural competence to Reduce Health Disparities [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; 2016. Accessed December 5, 2019. 

[6] Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc. 2008;100(11):1275-85.

[7] Brach C, Fraser I. Reducing disparities through culturally competent health care: An analysis of the business case. Qual Manag Health Care. 2002;10(4):15-28.

[8] Orgera K, Artiga S. Disparities in Health and Health Care: Five Key Questions and Answers. Published August 8, 2018. Accessed December 5, 2019.

[9] Piccardi C, Detollenaere J, Vanden bussche P, Willems S. Social disparities in patient safety in primary care: a systematic review. Int J Equity Health. 2018;17(1):114.

[10] Okoroh JS, Uribe EF, Weingart S. Racial and Ethnic Disparities in Patient Safety. J Patient Saf. 2017;13(3):153-161

[11] Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60-7.

[12] Stockwell DC, Landrigan CP, Toomey SL, et al. Racial, Ethnic, and Socioeconomic Disparities in Patient Safety Events for Hospitalized Children. Hosp Pediatr. 2019;9(1):1-5.

[13] Shepard S. Challenges of Cultural Diversity in Healthcare: Protect Your Patients and Yourself. Published May 2019. Accessed December 19, 2019. 

[14] Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc. 2008;100(11):1275-85.

[15] Beverley M. Connect Patient Engagement and Cultural competence to Drive Health Management. Published August 14, 2014. Accessed December 5, 2019.

[16]  Brach C, Fraser I, Paez K. Crossing the language chasm. Health Aff. 2005;24(2):424-34.

[17] Wasserman M, Renfrew MR, Green AR, et al. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual. 2014;36(3):5-16.

[18] Alexander GK, Uz SW, Hinton I, Williams I, Jones R. Culture brokerage strategies in diabetes education. Public Health Nurs. 2008;25(5):461-70.

[19] What is the Role of Cultural Brokers in Health Care Delivery? Accessed December 5, 2019. 

[20] Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57(Supplement 1):181-217.

[21] Truong M, Paradies Y, Priest N. Interventions to improve cultural competency in healthcare: A systematic review of reviews. BMC Health Services Research. 2014;14(1):99

[22] Re-Engineered Discharge (RED) Toolkit – Tool 4: How To Deliver the Re-Engineered Discharge to Diverse Populations. Published March 2013. Accessed December 5, 2019.

[23] Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Ann Intern Med. 2009;150(3):178-87.

[24] Patients With Limited English Proficiency. Accessed December 5, 2019.

[25] TeamSTEPPS Case Studies. Accessed December 5, 2019.

[26] Wasserman M, Renfrew MR, Green AR, et al. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual. 2014;36(3):5-16.

[27] Improving Patient Safety systems for Patients With Limited English Proficiency. Accessed December 5, 2019.

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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