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Policy Innovation Profile

State Legislation Requires Inclusion of Cultural and Linguistic Competence in Continuing Medical Education, Increasing Acceptance of Their Importance by Educational Programs and Clinicians


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Summary

The state of California passed legislation requiring that continuing medical education courses include curricula related to cultural and linguistic competence in medical practice. To promote adherence to this legislation, the Institute for Medical Quality, which accredits providers of continuing medical education in California, developed an accreditation standard related to cultural and linguistic competence and offers various services to help in complying with this standard. The legislation and accompanying support have been successful in ensuring the inclusion of cultural and linguistic competence in educational offerings and in fostering a deeper understanding of the importance of these competencies among providers of continuing medical education services and the clinicians they serve.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of CME providers meeting standards for accreditation (including those related to cultural and linguistic competence), along with anecdotal reports from program leaders about shifts in understanding and attitudes among CME providers and clinicians.
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Developing Organizations

California Medical Association; Institute for Medical Quality; State of California
A number of advocacy groups and legislators participated in the development of the legislation.end do

Date First Implemented

2006
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Patient Population

Vulnerable Populations > Non-english speaking/limited english proficiencyend pp

Problem Addressed

A lack of cross-cultural awareness by providers can lead to health disparities and less effective patient care, due in large part to poor communication and misunderstandings between patients and physicians. Although training on cultural competence can improve provider understanding of cultural issues and provider–patient communication, it is not widely available.1,2
  • Lack of cross-cultural awareness as cause of disparities: People of color frequently receive a lower standard of care than do their white counterparts, even when income, insurance status, age, and severity of conditions are comparable. Key factors contributing to these disparities include cultural and linguistic barriers within the health care system, greater clinical uncertainty among providers when interacting with minority patients, and beliefs or stereotypes held by providers about the health or behaviors of minorities.1
  • Linguistic barriers as a particular concern: Language barriers between patients and providers remain common and can have a negative impact on health care access and quality.3,4 Minority patients with limited English proficiency are less likely to develop a rapport with physicians, receive adequate information, and participate in medical decisionmaking.5 In California, an estimated 12.4 million people speak a language other than English at home (including one-half of those living in the San Francisco Bay area), and more than 6 million have limited English proficiency.6 Providers and patients in Los Angeles County face a particularly large linguistic challenge, because the county includes communities of people who speak Spanish, Chinese, Tagalog, Korean, Armenian, Vietnamese, Farsi, Japanese, Russian, French, Arabic, Cambodian, German, Italian, Hebrew, and various languages of the Pacific Islands.6
  • Unrealized potential of provider education: Education that incorporates culturally and linguistically competent attitudes, knowledge, and skills can be an important tool in improving providers' understanding of the cultural aspects of health care, building effective patient communication, and reducing health disparities.1 Yet providers seldom have access to such education, including through continuing medical education (CME) courses.1,2

What They Did

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Description of the Innovative Activity

The state of California passed legislation requiring that CME courses include curricula related to cultural and linguistic competence in medical practice. To promote adherence, the Institute for Medical Quality (IMQ)—a subsidiary of the California Medical Association (CMA) and recognized accreditor of CME in California—developed an accreditation standard related to these competencies and provides support to those offering CME services in complying with the standard. Key components of the enabling legislation and implementation support are outlined below:
  • Enabling legislation: Signed into law on October 4, 2005, Assembly Bill 1195 (AB 1195) was designed “to meet the cultural and linguistic concerns of a diverse patient population through appropriate professional development.”7 The bill specifies that patient-related CME courses include curricula related to cultural and linguistic competence in medical practice, and required implementation of associated accreditation standards before July 1, 2006. As specified by the law, a CME provider (including education and publishing companies, hospitals, medical groups, insurers, and professional and specialty societies) can satisfy the legislative requirement by doing at least one of the following:7
    • Incorporating cultural competence into curricula: CME courses can meet this requirement by identifying any cultural or linguistic disparity relevant to the educational gap they are addressing through a CME activity and incorporating into the activity appropriate objectives and content. The curricula may highlight how physicians can communicate effectively with the target population in its native language and how they can use cultural information to establish relationships, gather and incorporate cultural information related to diagnosis and treatment, and understand and apply cultural and ethnic data to care processes.
    • Providing education on translation and interpretation: CME courses can discuss resources and strategies that providers can use to ensure the availability of translation and interpretation services.
    • Providing education on relevant laws and regulations: CME courses can include a review and explanation of Federal and State laws and regulations regarding linguistic access.
  • Accreditation standards: Following passage of the legislation, IMQ established specific standards related to cultural and linguistic competence, as outlined below. The Institute confirms that CME providers meet or exceed these and other standards as part of its ongoing accreditation-related activities.
    • Stated mission related to cultural competence: The CME provider acknowledges the importance of culture and communication for delivering effective health care within its mission statement and establishes a commitment to educate physicians to deliver culturally and linguistically appropriate care.
    • Identification of gaps: For each patient care–related educational activity, the CME provider determines if there is evidence of health disparities linked to cultural or linguistically related practice gaps in the target group of physician learners (i.e., inadequate knowledge, competence, or performance) or their patients. CME providers that do not identify any disparities or practice gaps must document that fact.
    • Educational components to address gaps: Whenever the CME provider identifies a cultural or linguistic disparity relevant to the professional practice gap for the educational activity it is planning, it must generate at least one component within the activity to address the disparity.
  • Support in meeting accreditation standards: IMQ offers the following services to help CME providers meet all its accreditation standards, including those related to cultural and linguistic competence:
    • Onsite education from trained physicians: Trained, credentialed physicians known as surveyors evaluate CME programs to determine compliance with accreditation standards. As part of this review, they offer onsite, personalized education on how to incorporate cultural and linguistic competence into educational offerings.
    • Conferences and workshops: Following the bill’s passage, IMQ held conferences, workshops, and training programs for CME providers and clinicians that specifically addressed the bill’s requirements and that outlined how cultural and linguistic competence can be incorporated into CME materials and routine medical practice. IMQ continues to hold an annual conference and periodically hosts workshops on the development of educational programs that meet all accreditation standards. These programs routinely integrate messages about cultural and linguistic competence.
    • Quarterly newsletter: IMQ's quarterly newsletter periodically includes articles focused on cultural and linguistic competence, and authors may integrate messages about these competencies into other articles as well.
    • Individualized assistance and consultation: For 4 years after passage of the legislation, IMQ employed dedicated staff who responded to questions from CME providers and clinicians, provided feedback to those developing new CME programs, and connected callers to “mentors” in the medical community who could offer assistance. CME staff continue to offer CME providers support in how to comply with the cultural and linguistic competence standard, but unfortunately, they cannot spend as much time or provide as indepth assistance as they did previously.
    • Resource library: IMQ has a resource library that includes a variety of materials on cultural and linguistic competence, including journal articles, online tools from reputable organizations, disease- and population-specific resources, and databases with demographic and health statistics; this library is not current.

Context of the Innovation

Launched in 1996 as a subsidiary of the CMA, IMQ serves as the organization designated by the Accreditation Council for Continuing Medical Education as California’s intrastate accrediting agency. A nonprofit organization, IMQ offers educational, accreditation, consulting, and certification programs to providers. It also manages CME activities for CMA and its nonprofit affiliates.

The impetus for the legislation came from leaders within various ethnic groups in California who expressed concerns about a general lack of cultural and linguistic competence among providers. In response, legislators began drafting a bill that would have required all California physicians to take a single course on cultural and linguistic competence. CMA representatives opposed this approach, believing that mandating one course that isolated cultural competence as a separate topic would not effectively address the problem. Instead, they proposed integrating cultural and linguistic competence into care-oriented CME courses, believing this strategy would better help providers improve over time. CMA representatives worked with other advocacy groups and State legislators to develop Assembly Bill 1195, which required the Medical Board of California to ensure development of an accreditation standard for cultural and linguistic competence for CME programs. The Medical Board asked CMA and IMQ to act on its behalf in this matter.

Did It Work?

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Results

The legislation and accompanying support have been successful in ensuring the inclusion of cultural and linguistic competence in CME offerings and in fostering a deeper understanding of the importance of these competencies among providers of CME services and the clinicians they serve.
  • Widespread inclusion in CME programs: As of March 2013, 247 CME providers have earned accreditation, all of whom by definition have incorporated cultural and linguistic competence into their educational programs.
  • Greater understanding of importance of cultural and linguistic competence: IMQ representatives report that key stakeholders, including providers of CME services and clinicians who complete their programs, have developed a deeper understanding of cultural and linguistic competence and its importance in medical care, and have demonstrated an increased desire to incorporate these competencies into medical education offerings and the everyday practice of medicine. Although the realities of California's demographic changes have led in part to these changes in attitude, Institute leaders believe that the legislation and accompanying support activities have increased the speed and intensity of the shift.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of CME providers meeting standards for accreditation (including those related to cultural and linguistic competence), along with anecdotal reports from program leaders about shifts in understanding and attitudes among CME providers and clinicians.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Developing communications plan: IMQ developed a communications plan to inform CME providers about the legislation and new expectations regarding educational programming. These communications noted that IMQ would be developing new standards related to cultural and linguistic competence as part of its accreditation process, and that it would support CME providers in meeting these standards.
  • Developing basic standard: Initially, IMQ required CME providers to document only a “good-faith effort” in incorporating cultural and linguistic competence into educational programs.
  • Securing funding: IMQ secured a 2-year grant from the California Endowment to fund implementation activities, including hiring dedicated staff. The California Endowment later provided a second 2-year grant to continue funding these types of activities.
  • Hiring staff: IMQ hired a program administrator and coordinator to oversee implementation of activities related to cultural and linguistic competence. These individuals helped develop the workshops, meetings, brochures, and resource library, and fielded questions from CME providers and clinicians.
  • Enhancing standard: After several months, IMQ enhanced the standard by laying out specific expectations related to the integration of cultural and linguistic competence into educational activities.
  • Incorporating cultural and linguistic competence into general services: Over time, IMQ incorporated messages and lessons about cultural and linguistic competence into its ongoing communications and service offerings.

Resources Used and Skills Needed

  • Staffing: During the first 4 years, IMQ employed a full-time administrator and a part-time coordinator for activities related to cultural and linguistic competence. At present, IMQ does not dedicate any staff to these areas. Instead, existing staff handle activities related to cultural and linguistic competence as part of their regular duties.
  • Costs: Total development costs for this initiative are not available; funds were used to cover the salaries and benefits for dedicated staff, along with the development and delivery of various educational activities (e.g., written materials, conferences, workshops). No data are available on ongoing operating costs for the program; these activities are now considered part of IMQ's overall mission and consequently are funded out of its general operating budget.
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Funding Sources

California Endowment; Institute for Medical Quality
The California Endowment provided two grants to support IMQ activities related to implementation of the legislation. As noted, the ongoing costs of activities related to cultural and linguistic competence come out of the Institute's general operating budget.end fs

Tools and Other Resources

The California Endowment commissioned a report and toolkit on linguistic competence for providers. Titled Addressing Language Issues in Your Practice: A Toolkit for Physicians and Their Staff Members, the report is available at: http://www.calendow.org/uploadedFiles/language_access_issues.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Adoption Considerations

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Getting Started with This Innovation

  • Define cultural and linguistic competence broadly: Rather than developing a definition and associated activities that targeted particular population groups, the Institute defined cultural and linguistic competence broadly to reflect a patient-focused approach that considers the unique qualities and needs of every patient. This strategy helped ensure that the vast majority of CME providers and clinicians recognized the importance of cultural and linguistic competence to the provision of high-quality care, even those who believed they already understood the needs of one or more specific minority groups.
  • Create easy opportunities for early success: As noted, CME providers could initially meet the accreditation standard by showing a good-faith effort, thereby easing them into the law’s new requirements. This positive experience helped CME providers accept the law and realize on their own terms that incorporating cultural and linguistic competence into educational programs would enhance their value. As a result, they ended up being well prepared to meet the higher expectations that came along when the accreditation standards became more rigorous.

Sustaining This Innovation

  • Emphasize contribution of cultural and linguistic competence to new care models: Help CME providers and clinicians sustain their interest by emphasizing how the provision of culturally and linguistically competent care fits into new care models, including patient-centered medical homes and accountable care organizations.
  • Maintain support activities if funding allows: If funding allows, continue to offer CME providers education and customized support in incorporating cultural and linguistic competence into their program offerings. Ideally, an ongoing source of funding can be found to enable dedicated staff to offer such support.
  • Leverage community resources: After external grant funding runs out, program leaders will need to identify community-based resources to support the program, such as individual clinicians who are skilled at cultural and linguistic competence.

More Information

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Contact the Innovator

Jill Silverman, MSPH
President and CEO
Institute for Medical Quality
180 Howard Street, Suite 210
San Francisco, CA 94105
(415) 882-5169
E-mail: jsilverman@imq.org

K.M. Tan, MD
Acting Chair, CME Committee
Institute for Medical Quality
180 Howard Street, Suite 210
San Francisco, CA 94105
(415) 882-5151

Innovator Disclosures

Ms. Silverman and Dr. Tan reported having no financial interests or business/professional affiliations relevant to the work described in this profile, other than the funders listed in the Funding Sources section.

References/Related Articles

More information on this program from the IMQ Web site is available at: http://www.imq.org/.

Institute for Medical Quality. Cultural & linguistic competency in CME. PowerPoint presentation delivered at the IMQ CME Essentials Workshop; 2013 March 13-14; San Marino, CA.

More information about Assembly Bill 1195 is available through the University of California Los Angeles Office of Continuing Medical Education: http://www.cme.ucla.edu/cultural

 

Footnotes

1 Institute of Medicine. Unequal treatment: what healthcare providers need to know about racial and ethnic disparities in healthcare. 2002. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2003/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care
/Disparitieshcproviders8pgFINAL.pdf
.
2 U.S. Department of Health and Human Services Office of Minority Health. Teaching cultural competence in health care: a review of current concepts, policies and practices. 2002. Available at: http://minorityhealth.hhs.gov/assets/pdf/checked/1/em01garcia1.pdf.
3 Hampers LC, McNulty JE. Professional interpreters and bilingual physicians in a pediatric emergency department. Arch Pediatr Adolesc Med. 2002;156(11):1108-13. [PubMed]
4 Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med. 2007;22 Suppl 2:324-30. [PubMed]
5 Ferguson W, Candib LM. Culture, language, and the doctor-patient relationship. Fam Med. 2002;34(5):353-61. [PubMed]
6 The California Endowment. Addressing Language Issues in Your Practice: A Toolkit for Physicians and Their Staff Members. 2005. Available at: http://www.calendow.org/uploadedfiles/language_access_issues.pdf.
7 California State Legislature. Assembly Bill No. 1195. 2005 Sept 6.
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Original publication: September 25, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: September 25, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.