National Standards for 

Culturally and Linguistically 

Appropriate Services in 

Health Care 

FINAL REPORT 

U.S. Department of Health and Human Services, OPHS 

O ffice of Minority Health 

March 2001 

Washington, D.C. 
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


March 2001 

Prepared by: 

IQ Solutions, Inc. 

11300 Rockville Pike 

Suite 801 

Rockville, MD 20852 

Prepared for: 

Office of Minority Health 

U.S. Department of Health 

and Human Services 

Under Contract No. 282-99-0039 

Table of Contents 

ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v


PROJECT OVERVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1


NATIONAL STANDARDS FOR CULTURALLY AND LINGUISTICALLY


APPROPRIATE SERVICES IN HEALTH CARE . . . . . . . . . . . . . . . . . . . . . . . .3


NARRATIVE OUTLINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21


PART I: BACKGROUND AND PURPOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . .23


INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25


Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36


PART II: INDIVIDUAL STANDARDS WITH DISCUSSION . . . . . . . . . . . .45


INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47


Standard 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49


Standard 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54


Standard 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59


Standard 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65


Standard 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70


Standard 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72


Standard 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77


Standard 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83


Standard 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88


Standard 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92


Standard 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98


Standard 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102


Standard 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106


Standard 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109


PART III: METHODOLOGY AND ANALYSIS . . . . . . . . . . . . . . . . . . . . . . .113


INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115


Development of the Draft CLAS Standards: Stage One . . . . . . . . . . . . . . . . . . . .115


Public Comment on and Revision of the CLAS Standards: Stage Two . . 116


National Project Advisory Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117


PART IV: BIBLIOGRAPHY AND GLOSSARY . . . . . . . . . . . . . . . . . . . . . . .121


BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123


GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131


APPENDIX A


National Advisory Council Member List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A-3


Public Comment Regional Meetings Participants Lists


San Francisco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A-7


Baltimore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A-17


Chicago . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A-33


Appendix B 

Source of Written Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B-3


ACKNOWLEDGMENTS 

This report is the result of a multiyear process that involved countless numbers of special 

individuals across the United States and beyond. We extend our appreciation to them: 

• The National Project Advisory Committee (NPAC), for their dedication and tireless efforts 

in deliberating on countless drafts of the CLAS standards and their provision of 

comments, opinions, and expertise during the many months of revisions. A complete list 

of NPAC members appears in Appendix A. 

• The individuals and organizations whose written comments helped to shape the final 

CLAS standards, and the hundreds of participants who attended the three regional 

meetings held as part of the public comment process. Information and feedback garnered 

at these sessions guided the development of the final version of the standards. Rosters of 

all who wrote comments and attended the regional meetings appear in Appendix A. 

• Dr. Nathan Stinson, Deputy Assistant Secretary for Minority Health, U.S. Department of 

Health and Human Services, for his ongoing support and commitment to the project. 

• Ms. Valerie Welsh, Evaluation Officer, U.S. Department of Health and Human Services, 

Office of Minority Health (OMH), who was instrumental in acquiring funding for the 

launching of the project. 

• Mr. Guadalupe Pacheco of the Department of Health and Human Services Office of


Minority Health (OMH) for his vision of conceiving the project and his substantive


intellectual and personal contributions in his role as Project Officer.


• The core project staff for their indefatigable labor and efforts throughout the duration of 

this project: 

- C. Godfrey Jacobs of IQ Solutions, who served as Project Director. 

- Julia Puebla Fortier of Resources for Cross Cultural Health Care, who was Principal 

Investigator. 

- Gale Harris of IQ Solutions, who contributed as a Senior Writer. 

- Monica Barnhart of IQ Solutions, who served as a Senior Research Associate. 

- Michael Huddleston and Eileen Alexander of IQ Solutions, who served as Graphic 

Designers. 

Office of Minority Health v 

PROJECT OVERVIEW


As the U.S. population becomes more diverse, medical providers and other people involved in 

health care delivery are interacting with patients/consumers from many different cultural and 

linguistic backgrounds. Because culture and language are vital factors in how health care 

services are delivered and received, it is important that health care organizations and their 

staff understand and respond with sensitivity to the needs and preferences that culturally and 

linguistically diverse patients/consumers bring to the health encounter. Providing culturally 

and linguistically appropriate services (CLAS) to these patients has the potential to improve 

access to care, quality of care, and, ultimately, health outcomes. 

Unfortunately, a lack of comprehensive standards has left organizations and providers with no 

clear guidance on how to provide CLAS in health care settings. In 1997, the Office of Minority 

Health (OMH) undertook the development of national standards to provide a much-needed 

alternative to the current patchwork of independently developed definitions, practices, and 

requirements concerning CLAS. The Office initiated a project to develop recommended 

national CLAS standards that would support a more consistent and comprehensive approach 

to cultural and linguistic competence in health care. 

The first stage of the project involved a review and analysis of existing cultural and linguistic 

competence standards and measures, the development of draft standards, and revisions based 

on a review by a national advisory committee. The second stage focused on obtaining and 

incorporating input from organizations, agencies, and individuals that have a vital stake in the 

establishment of CLAS standards. Publication of standards in the Federal Register on 

December 15, 1999, announced a 4-month public comment period, which provided three 

regional meetings and a Web site as well as traditional avenues (mail and fax) for submitting 

feedback on the CLAS standards. A project team (consisting of staff members of OMH, its 

contractor, and subcontractor) analyzed public comments from 413 individuals or 

organizations and proposed revised standards, with accompanying commentaries, to a 

National Project Advisory Committee (NPAC). Deliberations and additional review by NPAC 

members informed further refinements of the standards. 

In their final version, the CLAS standards reflect input from a broad range of stakeholders, 

including hospitals, community-based clinics, managed care organizations, home health 

agencies, and other types of health care organizations; physicians, nurses, and other providers; 

professional associations; State and Federal agencies and other policymakers; purchasers of 

health care; accreditation and credentialing agencies; educators; and patient advocates, 

advocacy groups, and consumers. 

The CLAS standards were published in final form in the Federal Register on December 22, 

2000, as recommended national standards for adoption or adaptation by stakeholder 

organizations and agencies. A preamble and the fourteen CLAS standards follow. 

Office of Minority Health 1 

STANDARDS


National Standards for Culturally and Linguistically 

Appropriate Services in Health Care 

Preamble 

The following national standards issued by the U.S. Department of Health and Human 

Services’ (HHS) Office of Minority Health (OMH) respond to the need to ensure that all 

people entering the health care system receive equitable and effective treatment in a culturally 

and linguistically appropriate manner. These standards for culturally and linguistically 

appropriate services (CLAS) are proposed as a means to correct inequities that currently exist 

in the provision of health services and to make these services more responsive to the 

individual needs of all patients/consumers. The standards are intended to be inclusive of all 

cultures and not limited to any particular population group or sets of groups; however, they 

are especially designed to address the needs of racial, ethnic, and linguistic population groups 

that experience unequal access to health services. Ultimately, the aim of the standards is to 

contribute to the elimination of racial and ethnic health disparities and to improve the health 

of all Americans. 

The CLAS standards are primarily directed at health care organizations; however, individual 

providers are also encouraged to use the standards to make their practices more culturally and 

linguistically accessible. The principles and activities of culturally and linguistically 

appropriate services should be integrated throughout an organization and undertaken in 

partnership with the communities being served. 

The 14 standards are organized by themes: Culturally Competent Care (Standards 1-3), 

Language Access Services (Standards 4-7), and Organizational Supports for Cultural 

Competence (Standards 8-14). Within this framework, there are three types of standards of 

varying stringency: mandates, guidelines, and recommendations as follows: 

CLAS mandates are current Federal requirements for all recipients of Federal funds (Standards 

4, 5, 6, and 7). 

CLAS guidelinesare activities recommended by OMH for adoption as mandates by Federal, 

State, and national accrediting agencies (Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13). 

CLAS recommendationsare suggested by OMH for voluntary adoption by health care


organizations (Standard 14).


The standards are also intended for use by: 

• Policymakers, to draft consistent and comprehensive laws, regulations, and contract 

language. This audience would include Federal, State and local legislators, administrative 

and oversight staff, and program managers. 

• Accreditation and credentialing agencies, to assess and compare providers who say they 

offer culturally competent services and to assure quality for diverse populations. This 

audience would include the Joint Commission on Accreditation of Healthcare 

Organizations, the National Committee for Quality Assurance, professional organizations 

such as the American Medical Association and American Nurses Association, and quality 

review organizations such as peer review organizations. 

Office of Minority Health 3 
National Standards for CLAS in Health Car e 

• Purchasers, to advocate for the needs of ethnic consumers of health benefits, and leverage 

responses from insurers and health plans. This audience would include government and 

employer purchasers of health benefits, including labor unions. 

• Patients, to understand their right to receive accessible and appropriate health care


services, and to evaluate whether providers can offer them.


• Advocates, to promote quality health care for diverse populations and to assess and 

monitor care being delivered by providers. The potential audience is wide, including legal 

services and consumer education/protection agencies; local and national ethnic, 

immigrant, and other community-focused organizations; and local and national nonprofit 

organizations that address health care issues. 

• Educators, to incorporate cultural and linguistic competence into their curricula and to 

raise awareness about the impact of culture and language on health care delivery. This 

audience would include educators from health care professions and training institutions, 

as well as educators from legal and social services professions. 

• The health care community in general, to debate and assess the applicability and adoption 

of culturally and linguistically appropriate health services into standard health care 

practice. 

The CLAS standards employ key concepts that are defined as follows: 

CLAS standards: 

The collective set of CLAS mandates, guidelines, and recommendations issued by the HHS 

Office of Minority Health intended to inform, guide, and facilitate required and recommended 

practices related to culturally and linguistically appropriate health services. 

Culture: 

“The thoughts, communications, actions, customs, beliefs, values, and institutions of racial, 

ethnic, religious, or social groups. Culture defines how health care information is received, 

how rights and protections are exercised, what is considered to be a health problem, how 

symptoms and concerns about the problem are expressed, who should provide treatment for 

the problem, and what type of treatment should be given. In sum, because health care is a 

cultural construct, arising from beliefs about the nature of disease and the human body, 

cultural issues are actually central in the delivery of health services treatment and preventive 

interventions. By understanding, valuing, and incorporating the cultural differences of 

America’s diverse population and examining one’s own health-related values and beliefs, 

health care organizations, practitioners, and others can support a health care system that 

responds appropriately to, and directly serves the unique needs of populations whose cultures 

may be different from the prevailing culture” (Katz, Michael. Personal communication, 

November 1998). 

Cultural and linguistic competence: 

“Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that 

come together in a system, agency, or among professionals that enables effective work in crosscultural situations. ‘Culture’ refers to integrated patterns of human behavior that include the 

4 U.S. Department of Health and Human Services 
STANDARDS


language, thoughts, communications, actions, customs, beliefs, values, and institutions of 

racial, ethnic, religious, or social groups. ‘Competence’ implies having the capacity to function 

effectively as an individual and an organization within the context of the cultural beliefs, 

behaviors, and needs presented by consumers and their communities” (Based on Cross, T., 

Bazron, B., Dennis, K., & Isaacs, M., (1989). Towards A Culturally Competent System of Care 

Volume I. Washington, DC: Georgetown University Child Development Center, CASSP 

Technical Assistance Center) 

Culturally and linguistically appropriate services: 

Health care services that are respectful of and responsive to cultural and linguistic needs. 

Health care organizations: 

Any public or private institution involved in any aspect of delivering health care services. 

Patients/consumers: 

Individuals, including accompanying family members, guardians, or companions, seeking 

physical or mental health care services, or other health-related services. 

Staff: 

Individuals employed directly by a health care organization, as well as those subcontracted or 

affiliated with the organization. 

Office of Minority Health 5 

STANDARDS


Standard 1. Health care organizations should ensure that patients/consumers 

receive from all staff members effective, understandable, and respectful care that 

is provided in a manner compatible with their cultural health beliefs and 

practices and preferred language. 

This standard constitutes the fundamental requirement on which all activities specified in the 

other CLAS standards are based. Its intent is to ensure that all patients/consumers receiving 

health care services experience culturally and linguistically competent encounters with an 

organization’s staff. The standard is relevant not only to staff, who ultimately are responsible 

for the kinds of interactions they have with patients, but also to their organizations, which 

must provide the managers, policies, and systems that support the realities of culturally 

competent encounters. 

Respectful care includes taking into consideration the values, preferences, and expressed needs 

of the patient/consumer. Understandable care involves communicating in the preferred 

language of patients/consumers and ensuring that they understand all clinical and 

administrative information. Effective care results in positive outcomes for patients/consumers, 

including satisfaction; appropriate preventive services, diagnosis, and treatment; adherence; 

and improved health status. 

Cultural competence includes being able to recognize and respond to health-related beliefs and 

cultural values, disease incidence and prevalence, and treatment efficacy. Examples of 

culturally competent care include striving to overcome cultural, language, and communications 

barriers; providing an environment in which patients/consumers from diverse cultural 

backgrounds feel comfortable discussing their cultural health beliefs and practices in the 

context of negotiating treatment options; using community workers as a check on the 

effectiveness of communication and care; encouraging patients/consumers to express their 

spiritual beliefs and cultural practices; and being familiar with and respectful of various 

traditional healing systems and beliefs and, where appropriate, integrating these approaches 

into treatment plans. When individuals need additional assistance, it may be appropriate to 

involve a patient advocate, case manager, or ombudsperson with special expertise in crosscultural issues. 

Ways to operationalize this standard include implementing all the other CLAS standards. For 

example, in accordance with Standard 3, ensure that staff and other personnel receive crosscultural education and training, and that their skills in providing culturally competent care are 

assessed through testing, direct observation, and monitoring of patient/consumer satisfaction 

with individual staff/personnel encounters. Assessment of staff and other personnel could also 

be done in the context of regular staff performance reviews or other evaluations that could be 

included in the organizational self-assessment called for in Standard 9. Health care 

organizations should provide patients/consumers with information regarding existing laws 

and policies prohibiting disrespectful or discriminatory treatment or marketing/enrollment 

practices. 

Office of Minority Health 7 
National Standards for CLAS in Health Car e 

Standard 2. Health care organizations should implement strategies to recruit, 

retain, and promote at all levels of the organization a diverse staff and leadership 

that are representative of the demographic characteristics of the service area. 

The diversity of an organization’s staff is a necessary, but not sufficient, condition for 

providing culturally and linguistically appropriate health care services. Although hiring 

bilingual individuals from different cultures does not in itself ensure that the staff is culturally 

competent and sensitive, this practice is a critical component to the delivery of relevant and 

effective services for all patients/consumers. Diverse staff is defined in the standard as being 

representative of the diverse demographic population of the service area and includes the 

leadership of the organization as well as its governing boards, clinicians, and administrative 

personnel. Building staff that adequately mirrors the diversity of the patient/consumer 

population should be based on continual assessment of staff demographics (collected as part of 

organizational self-assessment in accordance with Standard 9) as well as demographic data 

from the community maintained in accordance with Standard 11. Staff refers not only to 

personnel employed by the health care organization but also its subcontracted and affiliated 

personnel. 

Staff diversity at all levels of an organization can play an important role in considering the 

needs of patients/consumers from various cultural and linguistic backgrounds in the decisions 

and structures of the organization. Examples of the types of staff members whose backgrounds 

should reflect the community’s diversity include clinical staff such as doctors, nurses, and 

allied health professionals; support staff such as receptionists; administrative staff such as 

individuals in the billing department; clergy and lay volunteers; and high-level decisionmakers 

such as senior managers, corporate executives, and governing bodies such as boards of 

directors. 

Acknowledging the practical difficulties in achieving full racial, ethnic, and cultural parity 

within the workforce, this standard emphasizes commitment and a good-faith effort rather 

than specific outcomes. It focuses not on numerical goals or quotas, but rather on the 

continuing efforts of an organization to design, implement, and evaluate strategies for 

recruiting and retaining a diverse staff as well as continual quality evaluation of improvements 

in this area. The goal of staff diversity should be incorporated into organizations’ mission 

statements, strategic plans, and goals. Organizations should use proactive strategies, such as 

incentives, mentoring programs, and partnerships with local schools and employment 

programs, to build diverse workforce capacity. Organizations should encourage the retention 

of diverse staff by fostering a culture of responsiveness toward the ideas and challenges that a 

culturally diverse staff offers. 

8 U.S. Department of Health and Human Services 
STANDARDS


Standard 3. Health care organizations should ensure that staff at all levls and 

across all disciplines receive ongoing education and training in culturally and 

linguistically appropriate service delivery. 

Hiring a diverse staff does not automatically guarantee the provision of culturally competent 

care. Staff education and training are also crucial to ensuring CLAS delivery because all staff 

will interact with patients/consumers representing different countries of origin, acculturation 

levels, and social and economic standing. Staff refers not only to personnel employed by the 

health care organization but also its subcontracted and affiliated personnel. 

Health care organizations should either verify that staff at all levels and in all disciplines 

participate in ongoing CME- or CEU-accredited education or other training in CLAS delivery, 

or arrange for such education and training to be made available to staff. This training should 

be based on sound educational (i.e., adult learning) principles, include pre- and post-training 

assessments, and be conducted by appropriately qualified individuals. Training objectives 

should be tailored for relevance to the particular functions of the trainees and the needs of the 

specific populations served, and over time should include the following topics: 

• Effects of differences in the cultures of staff and patients/consumers on clinical and other 

wo r k f o rce encounters, including effects of the culture of American medicine and clinical tra i n i n g ; 

• elements of effective communication among staff and patients/consumers of different culture s 

and different languages, including how to work with interpreters and telephone language 

s e r v i c e s ; 

• strategies and techniques for the resolution of racial, ethnic, or cultural conflicts between staff and 

patients/consumers; 

• health care organizations’ written language access policies and pro c e d u res, including how to 

access interpreters and translated written materials; 

• the applicable provisions of: 

Title VI of the Civil Rights Act of 1964, 42 U.S.C. §2000d, 45 C.F.R. §80.1 et seq. (including 

Office for Civil Rights Guidance on Title VI of the Civil Rights Act of 1964, with respect to 

services for (LEP) individuals (65 Fed. Reg. 52762-52774, August 30, 2000); 

• health care organizations’ complaint/grievance pro c e d u re s ; 

• effects of cultural differences on health promotion and disease prevention, diagnosis and 

t reatment, and supportive, re h a b i l i t a t i ve, and end-of-life care ; 

• impact of poverty and socioeconomic status, race and racism, ethnicity, and sociocultural factors 

on access to care, service utilization, quality of care, and health outcomes; 

• differences in the clinical management of preventable and chronic diseases and conditions 

indicated by differences in the race or ethnicity of patients/consumers; and 

• effects of cultural differences among patients/consumers and staff upon health outcomes, patient 

satisfaction, and clinical management of preventable and chronic diseases and conditions. 

Organizations that conduct the trainings should involve community representatives in the 

development of CLAS education and training programs, in accordance with Standard 12. 

Office of Minority Health 9 
National Standards for CLAS in Health Car e 

Standard 4. Health care organizations must offer and provide language 

assistance services, including bilingual staff and interpreter services, at no cost to 

each patient/consumer with limited English pr oficiency at all points of contact, in 

a timely manner during all hours of operation. 

Standards 4, 5, 6, and 7 are based on Title VI of the Civil Rights Act of 1964 (Title VI) with 

respect to services for limited English proficient (LEP) individuals. Title VI requires all 

entities receiving Federal financial assistance, including health care organizations, take steps to 

ensure that LEP persons have meaningful access to the health services that they provide. The 

key to providing meaningful access for LEP persons is to ensure effective communication 

between the entity and the LEP person. For complete details on compliance with these 

requirements, consult the HHS guidance on Title VI with respect to services for (LEP) 

individuals (65 Fed. Reg. 52762-52774, August 30, 2000) at [www.hhs.gov/ocr/lep]. 

Language services, as described below, must be made available to each individual with limited 

English proficiency who seeks services, regardless of the size of the individual’s language 

group in that community. Such an individual cannot speak, read, or understand the English 

language at a level that permits him or her to interact effectively with clinical or nonclinical 

staff at a health care organization. (Patients needing services in American Sign Language 

would also be covered by this standard, although other Federal laws and regulations apply and 

should be consulted separately.) 

Language services include, as a first preference, the availability of bilingual staff who can 

communicate directly with patients/consumers in their preferred language. When such staff 

members are not available, face-to-face interpretation provided by trained staff, or contract or 

volunteer interpreters, is the next preference. Telephone interpreter services should be used as 

a supplemental system when an interpreter is needed instantly, or when services are needed in 

an unusual or infrequently encountered language. The competence and qualifications of 

individuals providing language services are discussed in Standard 6. 

10 U.S. Department of Health and Human Services 
STANDARDS


Standard 5. Health care organizations must provide to patients/consumers in 

their preferred language both verbal offers and written notices informing them o f 

their right to receive language assistance services. 

LEP individuals should be informed—in a language they can understand—that they have the 

right to free language services and that such services are readily available. At all points of 

contact, health care organizations should also distribute written notices with this information 

and post translated signage. Health care organizations should explicitly inquire about the 

preferred language of each patient/consumer and record this information in all records. The 

preferred language of each patient/consumer is the language in which he or she feels most 

comfortable in a clinical or nonclinical encounter. 

Some successful methods of informing patients/consumers about language assistance services 

include: a) using language identification or “I speak . . .” cards; b) posting and maintaining 

signs in regularly encountered languages at all points of entry; c) creating uniform procedures 

for timely and effective telephone communication between staff and LEP persons; and 

d) including statements about the services available and the right to free language assistance 

services in appropriate non-English languages in brochures, booklets, outreach materials, and 

other materials that are routinely distributed to the public. 

Office of Minority Health 11 
National Standards for CLAS in Health Car e 

Standard 6. Health care organizations must assure the competence of language 

assistance provided to limited English proficient patients/consumers by 

interpreters and bilingual staff. Family and friends should not be used to pr ovide 

interpretation services (except on request by the patient/consumer). 

Accurate and effective communication between patients/consumers and clinicians is the most 

essential component of the health care encounter. Patients/consumers cannot fully utilize or 

negotiate other important services if they cannot communicate with the nonclinical staff of 

health care organizations. When language barriers exist, relying on staff who are not fully 

bilingual or lack interpreter training frequently leads to misunderstanding, dissatisfaction, 

omission of vital information, misdiagnoses, inappropriate treatment, and lack of compliance. 

It is insufficient for health care organizations to use any apparently bilingual person for 

delivering language services—they must assess and ensure the training and competency of 

individuals who deliver such services. 

Bilingual clinicians and other staff who communicate directly with patients/consumers in 

their preferred language must demonstrate a command of both English and the target language 

that includes knowledge and facility with the terms and concepts relevant to the type of 

encounter. Ideally, this should be verified by formal testing. Research has shown that 

individuals with exposure to a second language, even those raised in bilingual homes, 

frequently overestimate their ability to communicate in that language, and make errors that 

could affect complete and accurate communication and comprehension. 

Prospective and working interpreters must demonstrate a similar level of bilingual proficiency. 

Health care organizations should verify the completion of, or arrange for, formal training in 

the techniques, ethics, and cross-cultural issues related to medical interpreting (a minimum of 

40 hours is recommended by the National Council on Interpretation in Health Care). 

Interpreters must be assessed for their ability to convey information accurately in both 

languages before they are allowed to interpret in a health care setting. 

In order to ensure complete, accurate, impartial, and confidential communication, family, 

friends or other individuals, should not be required, suggested, or used as interpreters. A 

patient/consumer may choose to use a family member or friend as an interpreter after being 

informed of the availability of free interpreter services unless the effectiveness of services is 

compromised or the LEP person’s confidentiality is violated. The health care organization’s 

staff should suggest that a trained interpreter be present during the encounter to ensure 

accurate interpretation and should document the offer and declination in the LEP person’s 

file. Minor children should never be used as interpreters, nor be allowed to interpret for their 

parents when they are the patients/consumers. 

12 U.S. Department of Health and Human Services 
STANDARDS


Standard 7. Health care organizations must make available easily understood 

patient-related materials and post signage in the languages of the commonly 

encountered groups and/or groups represented in the service area. 

An effective language assistance program ensures that written materials routinely provided in 

English to applicants, patients/consumers, and the public are available in commonly 

encountered languages other than English. It is important to translate materials that are 

essential to patients/consumers accessing and making educated decisions about health care. 

Examples of relevant patient-related materials include applications, consent forms, and 

medical or treatment instructions; however, health care organizations should consult OCR 

guidance on Title VI for more information on what the Office considers to be “vital” 

documents that are particularly important to ensure translation (65 Fed. Reg. 52762-52774, 

August 30, 2000) at [www.hhs.gov/ocr/lep]. 

Commonly encountered languages are languages that are used by a significant number or 

percentage of the population in the service area. Consult the OCR guidance for guidelines 

regarding the LEP language groups for which translated written materials should be provided. 

Persons in language groups that do not fall within these guidelines should be notified of their 

right to receive oral translation of written materials. 

Signage in commonly encountered languages should provide notices of a variety of patient 

rights, the availability of conflict and grievance resolution processes, and directions to facility 

services. Way-finding signage should identify or label the location of specific services (e.g., 

admissions, pediatrics, emergency room). Written notices about patient/consumer rights to 

receive language assistance services are discussed in Standard 5. 

Materials in commonly encountered languages should be responsive to the cultures as well as 

the levels of literacy of patients/consumers. Organizations should provide notice of the 

availability of oral translation of written materials to LEP individuals who cannot read or who 

speak nonwritten languages. Materials in alternative formats should be developed for these 

individuals as well as for people with sensory, developmental, and/or cognitive impairments. 

The obligation to provide meaningful access is not limited to written translations. Oral 

communication often is a necessary part of the exchange of information, and written materials 

should never be used as substitutes for oral interpreters. A health care organization that limits 

its language services to the provision of written materials may not be allowing LEP persons 

equal access to programs and services available to persons who speak English. 

Organizations should develop policies and procedures to ensure development of quality nonEnglish signage and patient-related materials that are appropriate for their target audiences. At 

a minimum, the translation process should include translation by a trained individual, back 

translation and/or review by target audience groups, and periodic updates. 

It is important to note that in some circumstances verbatim translation may not accurately or 

appropriately convey the substance of what is contained in materials written in English. 

Additionally, health care organizations should be aware of and comply with existing State or 

local nondiscrimination laws that are not superceded by Federal requirements. 

Office of Minority Health 13 
National Standards for CLAS in Health Car e 

Standard 8. Health care organizations should develop, implement, and promote a 

written strategic plan that outlines clear goals, policies, operational plans, and 

management accountability/oversight mechanisms to provide culturally and 

linguistically appropriate services. 

Successful implementation of the CLAS standards depends on an organization’s ability to 

target attention and resources on the needs of culturally diverse populations. The purpose of 

strategic planning is to help the organization define and structure activities, policy 

development, and goal setting relevant to culturally and linguistically appropriate services. It 

also allows the agency to identify, monitor, and evaluate system features that may warrant 

implementing new policies or programs consistent with the overall mission. 

The attainment of cultural competence depends on the willingness of the organization to learn 

and adapt values that are explicitly articulated in its guiding mission. A sound strategic plan 

for CLAS is integrally tied to the organization’s mission, operating principles, and service 

focus. Accountability for CLAS activities must reside at the highest levels of leadership 

including the governing body of the organization. Without the strategic plan, the organization 

may be at a disadvantage to identify and prioritize patient/consumer service need priorities. 

Designated personnel or departments should have authority to implement CLAS-specific 

activities as well as to monitor the responsiveness of the whole organization to the cultural 

and linguistic needs of patients/consumers. 

Consistent with Standard 12, the strategic plan should be developed with the participation of 

consumers, community, and staff who can convey the needs and concerns of all communities 

and all parts of the organization affected by the strategy. And, consistent with Standards 9, 10, 

and 11, the results of data gathering and self-assessment processes should inform the 

development and refinement of goals, plans, and policies. 

14 U.S. Department of Health and Human Services 
STANDARDS


Standard 9. Health care organizations should conduct initial and ongoing 

organizational self-assessments of CLAS-related activities and are encouraged to 

integrate cultural and linguistic competence-related measures into their internal 

audits, performance improvement programs, patient satisfaction assessments, and 

outcomes-based evaluations. 

Ideally, these self-assessments should address all the activities called for in the 14 CLAS 

standards. Initial self-assessment, including an inventory of organizational policies, practices, 

and procedures, is a prerequisite to developing and implementing the strategic plan called for 

in Standard 8. Ongoing self-assessment is necessary to determine the degree to which the 

organization has made progress in implementing all CLAS standards. The purpose of ongoing 

organizational self-assessment is to obtain baseline and updated information that can be used 

to define service needs, identify opportunities for improvement, develop action plans, and 

design programs and activities. The self-assessment should focus on the capacities, strengths, 

and weaknesses of the organization in meeting the CLAS standards. 

Integrating cultural and linguistic competence-related measures into existing quality 

improvement activities will also help institutionalize a focus on CLAS within the organization. 

Linking CLAS-related measures with routine quality and outcome efforts may help build the 

evidence base regarding the impact of CLAS interventions on access, patient satisfaction, 

quality, and clinical outcomes. 

Patient/consumer and community surveys and other methods of obtaining input are important 

components of organizational quality improvement activities. But they should not constitute 

the only method of assessing quality with respect to CLAS. When used, such surveys should 

be culturally and linguistically appropriate. 

Office of Minority Health 15 
National Standards for CLAS in Health Car e 

Standard 10. Health care organizations should ensure that data on the individual 

patient’s/consumer’s race, ethnicity, and spoken and written language are collected 

in health records, integrated into the organization’s management information 

systems, and periodically updated. 

The purposes of collecting information on race, ethnicity, and language are to: 

• Adequately identify population groups within a service area; 

• ensure appropriate monitoring of patient/consumer needs, utilization, quality of care, and 

outcome patterns; 

• prioritize allocation of organizational resources; 

• improve service planning to enhance access and coordination of care; and 

• assure that health care services are provided equitably. 

Collection of data on self-identified race/ethnicity should adhere to the standard procedures 

and racial and ethnic categories specified in the Office of Management and Budget’s most 

current policy directive and adapted in the U.S. Census 2000. To improve the accuracy and 

reliability of race and ethnic identifier data, health care organizations should adapt intake and 

registration procedures to facilitate patient/consumer self-identification and avoid use of 

observational/visual assessment methods whenever possible. Individuals should be allowed to 

indicate all racial and ethnic categories that apply. Health care organizations can enhance their 

information on subpopulation differences by collecting additional identifiers such as selfidentified country of origin, which provides information relevant to patient/consumer care 

that is unobtainable from other identifiers. 

The purpose of collecting information on language is to enable staff to identify the preferred 

mode of spoken and written communication that a patient/consumer is most comfortable 

using in a health care encounter. Language data also can help organizations develop language 

services that facilitate LEP patients/consumers receiving care in a timely manner. To improve 

the accuracy and reliability of language data, health care organizations should adapt 

procedures to document patient/consumer preferred spoken and written language. Written 

language refers to the patient/consumer preference for receiving health-related materials. Data 

collected on language should include dialects and American Sign Language. 

For health encounters that involve or require the presence of a legal parent or guardian who 

does not speak English (e.g., when the patient/consumer is a minor or severely disabled), the 

management information system record and chart should document the language not only of 

the patient/consumer but also of the accompanying adult(s). 

Health care organizations should collect data from patients/consumers at the first point of 

contact using personnel who are trained to be culturally competent in the data collection 

process. Health care organizations should inform patients/consumers about the purposes (as 

stated above) of collecting data on race, ethnicity, and language, and should emphasize that 

such data are confidential and will not be used for discriminatory purposes. No 

patient/consumer should be required to provide race, ethnicity, or language information, nor 

be denied care or services if he or she chooses not to provide such information. All 

patient/consumer data should be maintained according to the highest standards of ethics, 

confidentiality, and privacy, and should not be used for discriminatory purposes. 

16 U.S. Department of Health and Human Services 
STANDARDS


Standard 11. Health care organizations should maintain a current demographic, 

cultural, and epidemiological profile of the community as well as a needs 

assessment to accurately plan for and implement services that respond to the 

cultural and linguistic characteristics of the service area. 

The purpose of this standard is to ensure that health care organizations obtain a variety of 

baseline data and update the data regularly to better understand their communities, and to 

accurately plan for and implement services that respond to the cultural and linguistic 

characteristics of the service area. 

Health care organizations should regularly use a variety of methods and information sources 

to maintain data on racial and ethnic groups in the service area. It is important that health 

care organizations go beyond their own data, such as marketing, enrollment, and termination 

figures, which may provide an incomplete portrait of the potential patient/consumer 

population, many of whom may not be aware of or use the organization’s services. A more 

useful and in-depth approach would use data sources such as census figures and/or 

adjustments, voter registration data, school enrollment profiles, county and State health status 

reports, and data from community agencies and organizations. Both quantitative and 

qualitative methods should be used to determine cultural factors related to patient/consumer 

needs, attitudes, behaviors, health practices, and concerns about using health care services as 

well as the surrounding community’s resources, assets, and needs related to CLAS. Methods 

could include epidemiological and ethnographic profiles as well as focus groups, interviews, 

and surveys conducted in the appropriate languages spoken by the patient/consumer 

population. Health care organizations should not use the collected data for discriminatory 

purposes. 

In accordance with Standard 12, health care organizations should involve the community in 

the design and implementation of the community profile and needs assessment. 

Office of Minority Health 17 
National Standards for CLAS in Health Car e 

Standard 12. Health care organizations should develop participatory, 

collaborative partnerships with communities and utilize a variety of formal and 

informal mechanisms to facilitate community and patient/consumer involvement 

in designing and implementing CLAS-related activities. 

The culturally competent organization views responsive service delivery to a community as a 

collaborative process that is informed and influenced by community interests, expertise, and 

needs. Services that are designed and improved with attention to community needs and 

desires are more likely to be used by patients/consumers, thus leading to more acceptable, 

responsive, efficient, and effective care. As described below, this standard addresses two levels 

of consumer/patient and community involvement that are not token in nature, but involve 

working with the community in a mutual exchange of expertise that will help shape the 

direction and practices of the health care organization. 

Patients/consumers and community representatives should be actively consulted and involved 

in a broad range of service design and delivery activities. In addition to providing input on the 

planning and implementation of CLAS activities, they should be solicited for input on broad 

organizational policies, evaluation mechanisms, marketing and communication strategies, staff 

training programs, and so forth. There are many formal and informal mechanisms available 

for this, including participation in governing boards, community advisory committees, ad hoc 

advisory groups, and community meetings as well as informal conversations, interviews, and 

focus groups. 

Health care organizations should also collaborate and consult with community-based 

organizations, providers, and leaders for the purposes of partnering on outreach, building 

provider networks, providing service referrals, and enhancing public relations with the 

community being served. 

Related to Standard 11, health care organizations should involve relevant community groups 

and patients/consumers in the implementation of the community profile and needs 

assessment. 

18 U.S. Department of Health and Human Services 
STANDARDS


Standard 13. Health care organizations should ensure that conflict and grie vance 

resolution processes are culturally and linguistically sensitive and capable o f 

identifying, preventing, and resolving cross-cultural conflicts or complaints by 

patients/consumers. 

This standard requires health care organizations to anticipate and be responsive to the 

inevitable cross-cultural differences that arise between patients/consumers and the 

organization and its staff. Ideally, this responsiveness may be achieved by integrating cultural 

sensitivity and staff diversity into existing complaint and grievance procedures as well as into 

policies, programs, offices or committees charged with responsibility for patient relations, and 

legal or ethical issues. When these existing structures are inadequate, new approaches may 

need to be developed. 

Patients/consumers who bring racial, cultural, religious, or linguistic differences to the health 

care setting are particularly vulnerable to experiencing situations where those differences are 

not accommodated or respected by the health care institution or its staff. These situations may 

range from differences related to informed consent and advanced directives, to difficulty in 

accessing services or denial of services, to outright discriminatory treatment. Health care 

organizations should ensure that all staff members are trained to recognize and prevent these 

potential conflicts, and that patients are informed about and have access to complaint and 

grievance procedures that cover all aspects of their interaction with the organization. In 

anticipation of patients/consumers who are not comfortable with expressing or acting on their 

own concerns, the organization should have informal and formal procedures such as focus 

groups, staff-peer observation, and medical record review to identify and address potential 

conflicts. 

Among the steps health care organizations can take to fulfill this standard are: providing 

cultural competence training to staff who handle complaints and grievances or other legal or 

ethical conflict issues; providing notice in other languages about the right of each 

patient/consumer to file a complaint or grievance; providing the contact name and number of 

the individual responsible for disposition of a grievance; and offering ombudsperson services. 

Health care organizations should include oversight and monitoring of these culturally or 

linguistically related complaints/grievances as part of the overall quality assurance program for 

the institution. 

Office of Minority Health 19 
National Standards for CLAS in Health Car e 

Standard 14. Health care organizations are encouraged to regularly make 

available to the public information about their progress and successful 

innovations in implementing the CLAS standards and to provide public notice in 

their communities about the availability of this information. 

Sharing information with the public about a health care organization’s efforts to implement 

the CLAS standards can serve many purposes. It is a way for the organization to communicate 

to communities and patients/consumers about its efforts and accomplishments in meeting the 

CLAS standards. It can help institutionalize the CLAS standards by prompting the 

organization to regularly focus on the extent to which it has implemented each standard. It 

also can be a mechanism for organizations to learn from each other about new ideas and 

successful approaches to implementing CLAS. 

Health care organizations can exercise considerable latitude in both the information they make 

available and the means by which they report it to the public. For example, organizations can 

describe specific organizational changes or new programs that have been instituted in response 

to the standards, CLAS-related interventions or initiatives undertaken, and/or 

accomplishments made in meeting the needs of diverse populations. Organizations that wish 

to provide more in-depth information can report on the data collected about the populations 

and communities served in accordance with Standard 11 and the self-assessment results 

gathered from Standard 9. Organizations should not report scores or use data from selfassessment tools that have not been validated. However, as standard self-assessment 

instruments and performance measures are developed and validated, additional information 

gathered by using these tools could be made available to the public. 

Health care organizations can use a variety of methods to communicate or report information 

about progress in implementing the CLAS standards, including publication of stand-alone 

documents focused specifically on cultural and linguistic competence or inclusion of CLAS 

components within existing organizational reports and documents. Other channels for sharing 

this information include the organization’s member publications; newsletters targeting the 

communities being served; presentations at conferences; newspaper articles; television, radio, 

and other broadcast media; and postings on Web sites. 

20 U.S. Department of Health and Human Services 
NARRATIVE OUTLINE 

This report recommends national standards for culturally and linguistically appropriate 

services (CLAS) in health care. Based on an analytical review of key laws, regulations, 

contracts, and standards currently in use by Federal and State agencies and other national 

organizations, these standards were developed and refined with significant input from a 

nationwide public comment process and the guidance of two national project advisory 

committees. 

Part I of this report provides background on the importance of cultural competence in health 

care in the United States, reviews the role and interest of the U.S. Department of Health and 

Human Services and its Office of Minority Health in cultural competence, and briefly 

summarizes the process of developing national standards for CLAS in health care. It also 

explains the purpose, intended audience of and organizing principles behind the standards; 

reviews the most important general comments received on the standards; and discusses the 

implications of the CLAS standards for the U.S. health care system. Part I ends with 

recommendations for actions that could be taken in the public and private sector to facilitate 

implementation of the CLAS standards. 

Part II, which is the main section of the report, contains the 14 CLAS standards. In this 

section, each standard is accompanied by commentary that defines key concepts and issues 

and a discussion section that provides an overview of critical implementation issues. 

Part III of the report summarizes the process for developing and revising the CLAS standards 

over 3 years. The Methodology and Analysis section briefly reviews stage one of the process 

(1997-1999), describes in more detail stage two of the process (1999-2001), and summarizes 

the changes made to individual standards based on the analysis of public comments and input 

from the National Project Advisory Committee. 

Part IV presents a glossary of terms found within the standards. It also contains a 

bibliography of all sources used in preparing this final report. 

Attached Appendices include rosters of those who attended the three regional meetings held 

during the public comment period of the CLAS Standards’ development. The National Project 

Advisory Committee (NPAC) membership is also presented. 

Office of Minority Health 21 

PART I: BACKGROUND AND PURPOSE


PART I


INTRODUCTION 

This chapter provides background on the importance of cultural competence in health care in 

the United States, reviews the role and interest of the U.S. Department of Health and Human 

Services (HHS) and its Office of Minority Health (OMH) in cultural competence, and briefly 

summarizes the process of developing national standards for culturally and linguistically 

appropriate services (CLAS) in health care. It also explains the purpose, intended audience of, 

and organizing principles behind the standards; reviews the most important general comments 

received on the standards; and discusses the implications of the CLAS standards for the U.S. 

health care system. Part I ends with recommendations for actions that could be taken in the 

public and private sector to facilitate implementation of the CLAS standards. 

The Importance of Cultural Competence in Health Care 

Consistent with long-standing predictions, Census 2000 data has revealed significant increases 

in minority and foreign-born populations across the United States. California’s “minority” 

populations became the majority in 1999, and many other states not historically perceived as 

racially or ethnically diverse are yearly receiving thousands of newcomers from around the 

globe. The state of Iowa is actively recruiting immigrants and refugees, citing the opportunity 

to help resolve a growing worker shortage and declining population. 

The increasing diversity of the nation brings with it a host of opportunities and challenges 

that are experienced with increasing frequency and immediacy in health care facilities, from 

small rural clinics to large urban medical centers. Sensitivity, empathetic listening, and a little 

extra effort can often go a long way to bridge the gap between the staff of health care 

organizations and patients who bring cultural differences to the health encounter. But these 

personal efforts are usually not enough to overcome the common organizational barriers 

presented by mainstream health care organizations. These barriers affect how diverse patient 

populations navigate their health care and how health care organizations and providers deliver 

that care. 

The notion of cultural competence has been promoted for many years as the way for health 

care providers and health care organizations to understand and respond effectively to the 

cultural and linguistic needs brought by patients to the health care encounter. Many excellent 

examples of culturally responsive organizations exist around the country, and many tools and 

resources are available to assist health care organizations improve their ability to serve diverse 

populations. 

Many national, state, and local policymakers have also recognized the importance of cultural 

competence in facilitating accessible and effective health care for culturally diverse 

populations. But many of these leaders are still in the early stages of defining cultural 

competence in a way that is measurable and enforceable. Some approaches to policymaking on 

cultural competence attempt to be comprehensive, while others target only a specific issue, 

geographic area, or subfield of health care such as mental health. The result is a wide 

spectrum of ideas about what constitutes culturally competent health services, including 

significant differences with respect to target population, scope, and quality of services. 

Office of Minority Health 25 
National Standards for CLAS in Health Car e 

The Role of HHS/OMH in Advancing Cultural Competence 

HHS has long been committed to improving access to health services for disadvantaged 

populations. In recent years, HHS has advanced several significant initiatives in this area, 

including the President’s initiative to eliminate racial and ethnic disparities in health care, and 

the issuance of guidance by the Office for Civil Rights (OCR) on equal access to services for 

individuals with limited English proficiency. 

Each agency of the Department has taken an independent approach to defining and addressing 

the health care needs of minority and foreign-born populations, but OMH often provides a 

focal point in HHS for these concerns. Created in 1986 to address the health needs and 

disparities experienced by minority populations in this country, OMH has provided more that 

$6.9 million dollars of seed funding to develop and promote models of cultural and linguistic 

competence. 

OMH’s work in cultural and linguistic competence includes demonstration projects, fellowship 

programs, training and technical assistance networks, data collection, and the development of 

monographs and models. Examples of OMH projects include the following: 

• Bilingual/Bicultural Service Demonstration Program—Developed in 1993, this program is 

designed to reduce social, cultural and linguistic barriers between providers and clients 

with limited-English proficiency and to improve their access to quality health care. 

• Grants for Centers of Excellence Bilingual and Bicultural Minority Pre-Faculty Fellowship 

Program—This demonstration program was launched to assess whether formal pre-faculty 

development programs would increase underrepresented minorities in faculty positions in 

health professions schools for the purpose of incorporating linguistic and culturally 

appropriate curriculum models. 

• Proyecto InformarTraining and Technical Assistance Network—This project focused on 

building the capacity of providers and institutions in providing cultural competency 

training to Hispanics. 

• Survey of local health departments—The survey, conducted by the National Association of 

County and City Health Officials with OMH’s support, acquired baseline data on county 

efforts to provide linguistically and culturally appropriate community health promotion 

programs to address racial/ethnic health disparities. 

• Monograph series—Five publications, supported by OMH, the Health Resources and 

Services Administration (HRSA), and the Substance Abuse and Mental Health Services 

Administration, addressed cultural competency service delivery issues of racial and ethnic 

populations. 

• Cultural competence practice models—The University of Texas, with OMH support, is 

developing a model for incorporating elements of cultural competence into their preclinical medical school curriculum for students and faculty. 

• Study of interpreters services—OMH supports research being conducted by the Portland 

State University to determine whether the introduction of professional interpreters 

services improves access to and use of health care services by language minority 

populations. 

26 U.S. Department of Health and Human Services 
PART I


• Assessment of managed care services—OMH is supporting a national assessment of 

culturally and linguistically appropriate services in managed care organizations serving 

racially/ethnically diverse populations. 

In the late 1990s, OMH began to concentrate on policy and research products to support the 

practice of culturally competent health care. The national standards presented in this report 

constitute a central part of OMH’s agenda to promote culturally and linguistically competent 

health care among organizations and policymakers in the United States. 

CLAS Standards Project Overview 

In 1997, OMH asked Resources for Cross Cultural Health Care (RCCHC) and the Center for 

the Advancement of Health to review and compare existing cultural and linguistic competence 

standards and measures in a national context, propose draft national standard language where 

appropriate, assess the information or research needed to relate these guidelines to outcomes, 

and develop an agenda for future work in this area. Assuring Cultural Competence in Health 

Care: Recommendations for National Standards and an Outcomes-Focused Research Agenda 

was the result of this request, with a two-part report submitted to OMH in May 1999. 

The first part of the 1999 report contained draft national standards for culturally and 

linguistically appropriate services in health care. Based on an analytical review of key laws, 

regulations, contracts, and standards currently in use by Federal and State agencies and other 

national organizations, these draft standards were developed with input from a national 

project advisory committee of policymakers, health care organizations, and researchers. Each 

standard was accompanied by a discussion that addressed the proposed guideline’s relationship 

to existing laws and standards, and offered recommendations for implementation and 

oversight to organizations, policymakers, and advocates. 

Following receipt of the report, OMH determined that the appropriate next step for the draft 

CLAS standards was to undergo a national process of public comment that would result in a 

broader awareness of HHS interest in CLAS in health care, significant input from stakeholder 

groups on the draft standards, and a final revision of the standards and accompanying 

commentary supported by the expertise of a second Project Advisory Committee. This task 

was assigned to IQ Solutions and its subcontractor RCCHC. 

The draft CLAS standards were published in the Federal Register on December 15, 1999 

(Volume 64, Number 240, pages 70042-70044), launching a four-month public comment 

period, which ran from January 1 to April 30, 2000. Individuals also had the opportunity to 

participate in one of three regional meetings on the CLAS standards. The purpose of these 

one-day meetings was to present information on the standards’ development process and for 

participants to discuss and provide feedback on issues related to the standards themselves or 

their implementation. Following the closure of the public comment period, the project team 

(consisting of staff members of IQ Solutions, RCCHC, and OMH) analyzed the public 

comments on the CLAS standards. These findings were presented to a National Project 

Advisory Committee (NPAC) composed of 27 individuals representing health care 

organizations, health care professionals, consumers, unions, State and Federal agencies, and 

health care accrediting agencies. 

Office of Minority Health 27 
National Standards for CLAS in Health Car e 

Following the meeting, the project team revised the standards based on the public comments 

and the deliberations of the NPAC. The final revisions are contained in this report and were 

published in the Federal Register on December 22, 2000 (Vol. 65, No. 247, pp. 80865-80879) 

as national standards for adoption or adaptation by stakeholder organizations and agencies. 

Purpose of the Standards and Intended Audience 

The CLAS standards are proposed as one means to correct inequities that currently exist in 

the provision of health services and to make these services more responsive to the individual 

needs of all patients/consumers. The standards are intended to be inclusive of all cultures and 

not limited to any particular population group or sets of groups. However, they are especially 

designed to address the needs of racial, ethnic, and linguistic population groups that 

experience unequal access to health services. Ultimately, the aim of the standards is to 

contribute to the elimination of racial and ethnic health disparities and to improve the health 

of all Americans. 

The CLAS standards serve several purposes. They provide a common understanding and 

consistent definitions of culturally and linguistically appropriate services in health care. They 

offer a practical framework for the implementation of services and organizational structures 

that can help health care organizations and providers be responsive to the cultural and 

linguistic issues presented by diverse populations. 

As mentioned above, the CLAS standards were initially derived from an analysis of current 

practice and policy on cultural competence, and shaped by the experiences and expertise of 

health care organizations, policymakers, and consumers. This process was guided by the 

following overarching definition of cultural competence: 

“Cultural and linguistic competence is a set of congruent behaviors, attitudes, and 

policies that come together in a system, agency, or among professionals that enables 

effective work in cross-cultural situations. ‘Culture’ refers to integrated patterns of 

human behavior that include the language, thoughts, communications, actions, 

customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. 

‘Competence’ implies having the capacity to function effectively as an individual and an 

organization within the context of the cultural beliefs, behaviors, and needs presented 

by consumers and their communities.” (Adapted from Cross, 1989). 

The final 14 standards are organized by themes: Culturally Competent Care (Standards 1-3), 

Language Access Services (Standards 4-7), and Organizational Supports for Cultural 

Competence (Standards 8-14). Standards 1-7 address interventions that have the most direct 

impact on clinical care. Standards 8-14 address organizational structures, policies and 

processes that support the implementation of the first seven standards. The 14 standards can 

also be categorized into three types of standards of varying stringency: mandates, guidelines, 

and recommendations as follows: 

CLAS mandates a re current Fe d e ral re q u i rements for all recipients of Fe d e ral funds 

( S t a n d a rds 4, 5, 6, and 7). 

CLAS guidelinesa re activities recommended by OMH for adoption as mandates by Fe d e ra l , 

S t a t e, and national accrediting agencies (Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13). 

28 U.S. Department of Health and Human Services 
PART I


CLAS re c o m m e n d a t i o nis suggested by OMH for voluntary adoption by health care 

o rganizations (Standard 14). 

The CLAS standards are primarily directed at health care organizations; however, individual 

providers are also encouraged to use the standards to make their practices more culturally and 

linguistically accessible. The principles and activities of CLAS should be integrated throughout 

an organization and undertaken in partnership with the communities being served. 

As stated in the 1999 report, the CLAS standards are also presented as guidelines for: 

Policymakers, to draft consistent and comprehensive laws, regulations and contract language. 

This audience would include Federal, state and local legislators, administrative and oversight 

staff, and program managers. 

Accreditation and credentialing agencies, to assess and compare organizations who say 

they provide culturally competent services, and to assure quality for diverse populations. This 

audience would include the Joint Commission on Accreditation of Healthcare Organizations, 

the National Committee on Quality Assurance, professional organizations such as the 

American Medical and Nurses associations, and quality review organizations such as Peer 

Review Organizations. 

Purchasers, to advocate for the needs of ethnic consumers of health benefits and to leverage 

responses from insurers and health plans. This audience would include government and 

employer purchasers of health benefits, including labor unions. 

Patients, to be able to understand their right to receive accessible and appropriate health care 

services, and to evaluate whether health care organizations and providers can offer such 

services. 

Advocates, to promote quality health care for diverse populations, and to assess and monitor 

care being delivered by health care organizations and providers. The potential audience is 

quite wide, including legal services and consumer education/protection agencies; local and 

national ethnic, immigrant and other community-focused organizations; and local and national 

nonprofit organizations that address health care issues. 

Educators, to incorporate cultural and linguistic competence into their curricula and to raise 

awareness about the impact of culture and language on health care delivery. This audience 

would include health care professions educators and training institutions, as well as legal and 

social services professions educators. 

The health care community in general, to debate and assess their applicability and 

adoption into standard health care practice. 

Major Issues Raised in Response to the CLAS Standards 

One of the great assets of the public comment process on the draft CLAS standards has been 

the collection of a wide variety of views and information about the role and practice of 

cultural and linguistic competence in American health care. The public comment process 

allowed individuals and organizations to comment on individual standards, as well as on the 

CLAS project overall. With respect to the project, commenters were invited to offer their 

views on any of the following topics: the concept of national standards for cultural and 

linguistic competence; the role of OMH and HHS in sponsoring this effort; the methodology 

Office of Minority Health 29 
National Standards for CLAS in Health Car e 

for developing the standards; and the implications of having national standards for 

organizations and policymakers. Seventy pages of general comments were received, and they 

offer a rich source of information and perspectives on the CLAS standards and cultural 

competence in health care generally (see the CLAS website at [www.omhrc.gov/CLAS] for the 

complete set of public comments received). The following discussion will summarize some 

key issues raised that have implications for the future acceptability and adoption of the CLAS 

standards. Specific responses by the project team to these and other issues will be discussed in 

more detail in the Methodology and Analysis section of the report (see Part III). 

Support for and Critiques of the Standards 

Public comment processes typically stimulate a wide range of opinions, and OMH received 

more than 20 pages of public comments that addressed issues related to support for, or 

criticism of, the concept of standards for CLAS. A few key observations can be made about the 

way different individuals and organizations perceived the notion of draft model standards. A 

number of commenters clearly did not understand that the draft standards printed in the 

Federal Register were not anticipated to be regulations in the near future. On the other hand, 

other comments indicated that many people were not aware of existing laws that address some 

issues raised by the CLAS standards. Many commenters who were aware of this relationship 

felt that some standards needed to be strengthened on the basis of those Federal requirements. 

Many comments raised questions about whether the recommended CLAS standards should be 

finalized as guidelines, standards, or mandates. Overall, there was a broad continuum of 

support for, and opposition to, different conceptualizations of the standards. Fifty comments 

supported the standards as mandates, with another 37 offering endorsement, support for their 

adoption, agreement with the intent, and other general expressions of praise. Thirty-four 

comments expressed some level of concern about seeing the standards as national standards or 

requirements. Some commenters preferred the standards as guidelines, and others disliked 

them in any format. Among the reasons for concern or opposition were the potential 

costs/burden of implementation; the perception that the standards were too broad, too narrow, 

or too prescriptive; and the lack of research evidence to support many CLAS activities. 

The following examples of public comments received reveal the variety of opinions articulated. 

“We understand the significance of this activity and the potential that the standards 

embody for improving health care outcomes. We share and support your concern for 

the need to develop and release clear guidance to plans and other providers as they 

respond to a rapidly growing culturally diverse population.” 

“To have any effect in practice, finalized standards must be more than mere 

‘guideposts.’ To the extent possible, the final standards should be issued as enforceable 

regulations. Without an enforcement mechanism to support the final standards, we 

fear many health care organizations and providers will not prioritize linguistic and 

cultural competence and our communities will continue to lack access to quality health 

care.” 

“We believe the standards are achievable for all states. [The Washington Department of 

Social and Health Services] and partners all agree that in order for cultural and 

linguistic competence to become commonplace in today’s health-care system, it has to 

30 U.S. Department of Health and Human Services 
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be embraced, supported, and made a priority by state and health care executive 

management.” 

“The American Academy of Pediatrics agrees with the intent of the DHHS 

recommendations for cultural competence standards. However, the Academy has 

concerns regarding the availability of education, training, qualified personnel, adequate 

reimbursement, evaluation mechanisms and other resources required to implement and 

comply with the standards.” 

“While perhaps serving as a good beginning, especially for organizations with little 

experience serving the minority populations, these recommendations do not define the 

essential elements for delivering CLAS. There’s also no firm evidence that utilizing 

these recommendations enhances acceptance and effectiveness of services by the target 

populations. It would be appropriate to recommend these as guidelines rather than 

standards and study the experience in their implementation for various populations 

before finalizing ‘standards’.” 

“Mayo Foundation [We do] not believe that culturally and linguistically appropriate 

health care services are an area of health care that should be highly regulated. When a 

guideline or standard is strictly mandated and regulated, all possible opportunities for 

flexibility and innovation are eliminated. This approach is not in the best interests of 

the patient or customer needing the service. We believe that health care institutions 

and other quality businesses will adopt the proposed principals as guidelines to ensure 

that they provide high-quality health care that encompasses the needs of the patient, 

the patient’s family, and the community.” 

Issues related to incentives, costs, reimbursement and other administrative concerns 

engendered more than 10 pages of public comments. Health care providers and provider 

organizations were particularly apprehensive about the impact of requiring the CLAS 

standards. They expressed concerns about the “unreasonable burden in costs and resources 

associated with the draft standards,” and noted that “if applied literally, they would likely 

overwhelm most hospitals’ and physicians’ resources — both time and money.” Home health 

care agencies were particularly adamant in their concerns about how the standards would 

affect their businesses. “Specifically, OMH’s proposed CLAS standards would require the 

financial resources to hire new and additional staff or contract services, as well as to develop 

new policies and procedures—new standards, training materials, and subsequent training of 

staff. Implementation of the proposed CLAS standards would be financially prohibitive for 

home care agencies that are struggling in the current Medicare and Medicaid environment. 

Providers are being asked to supply additional services without the ability to set prices, or to 

recoup the cost of unfunded mandates.” Cost constraints across the health care industry, 

especially in government-funded programs such as Medicare and Medicaid, were posed as 

inherently contradictory to the notion of government-sponsored requirements for additional 

expenditures related to culturally competent care. Several commenters suggested that 

financially strapped providers, especially those participating in low reimbursement programs, 

would likely opt out of continued participation in those programs if they were required to 

comply with the CLAS standards. 

Office of Minority Health 31 
National Standards for CLAS in Health Car e 

There were many calls for economic impact analyses of the CLAS standards and a 

demonstration of cost-effectiveness before the standards are mandated. At the same time, 

many commenters remarked on the need for better awareness of the cost-effectiveness 

arguments and existing evidence that already support culturally appropriate services. “The 

Washington Business Group on Health believes that employer consideration of cultural 

competence can lead to more efficient use of health dollars and can contribute to increased 

productivity and a reduction in absenteeism and disability. Increased patient compliance and 

satisfaction can improve health outcomes. As employers respond to an increasingly consumerdriven health system, emphasis on cultural competence and assessment of what services are 

available and how they’re delivered to a diverse workforce will become increasingly 

important.” 

For example, errors made due to cultural or linguistic misunderstandings in health care 

encounters can lead to repeat appointments, extra time spent rectifying misdiagnoses, 

unnecessary emergency room visits, longer hospital stays, and canceled diagnostic or surgical 

procedures. While cultural competence training and language assistance services require 

financial and staff resources, avoiding one costly lawsuit can finance a considerable number of 

activities related to the CLAS standards. However, while some supporting research exists, 

many of the proofs for the cost effectiveness of cultural competence services are anecdotal. As 

one commenter noted, “if only one thing was mandated, it should be the collection of cost 

effectiveness data” related to cultural and linguistic interventions. Community-based 

providers offered another interesting perspective. “Implementing the CLAS standards may be 

costly, but the costs of culturally and linguistically competent health care services currently are 

borne by small, grass-roots, community-based organizations which are least able to afford it. 

Implementing the standards will remove the ‘ethnic tax’ on providers who have always 

provided CLAS to people who often cannot afford to pay. The standards will ensure that 

others providing such services will share the costs.” 

It is impossible to adequately summarize and respond to all the supporting and detracting 

comments related to the CLAS standards, and those with further interest in these issues are 

encouraged to read the related public comments on the CLAS standards web site 

[http://www.omhrc.gov/clas]. All the preceding issues were raised in the analytical report 

prepared for the NPAC, recommended to the committee for special consideration, and 

discussed in detail at the committee meeting. In the end, the project team and the committee 

acknowledged that there is more hard evidence to support concerns about cost/burdens than 

there is to support the financial incentive argument for some CLAS activities. 

Notwithstanding this, the clinical, ethical, and social justice arguments for cultural and 

linguistic competence were more compelling to the group than arguments against it. The 

committee attempted to account for this dichotomy by suggesting a flexible implementation 

approach and recommendations for additional resources for health care organizations to 

implement the standards. 

Critiques on the Approach and Applicability of the Standards 

A wide spectrum of concerns was raised about the approach taken by the CLAS standards to 

articulate a set of cultural competence activities for health care organizations. The comments 

received suggest that different individuals and organizations perceived the standards very 

differently. Some commenters thought the standards were too prescriptive; others felt they 

32 U.S. Department of Health and Human Services 
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needed to be more specific. Issues were raised about the complexity, comprehensiveness, 

measurability, and flexibility of the standards. It is not possible to generalize by stakeholder 

types (e.g., health care providers or consumer advocates) whether these issues were raised as 

strengths or weaknesses. For example, one provider organization expressed great concern that 

the proposed standards were too general in nature and did not provide enough detail and 

direction to facilitate proper implementation and ensure compliance by the full range of health 

care organizations and providers. Another health provider organization felt that national 

standards would impede the current flexible and responsive approach used by their 

constituents, and create a “checklist” environment for determining compliance with a “set of 

rigid model requirements.” Generally, consumer advocates felt that the standards needed to be 

specific and directive requirements to sufficiently motivate health care organizations to take 

action. Health care providers generally felt that the standards in their draft iteration were too 

vague to be held accountable to in a fair manner, but they also feared a final product that was 

a collection of complex and burdensome requirements. 

A related set of concerns addressed how the CLAS standards might be applied to different 

types of health care organizations. Despite the stated focus on health care organizations, 

physician groups expressed considerable anxiety over their perceived inability to comply with 

the standards. Small health care organizations and those located in rural areas were also 

concerned how they would be able to address all the activities described in the standards. 

Home health care agencies consistently claimed that the CLAS standards constituted an 

impossible burden in the context of existing regulatory requirements and cutbacks in 

reimbursement. In light of these concerns, it is important to view the CLAS standards as a 

framework that describes the types of cultural competence activities that an organization 

should undertake in the context of its size, location, organizational type, and available 

resources. In the final version, some standards (related to language access services) are 

described as mandates. These standards simply reflect current Federal requirements for 

recipients of Federal funds. However, these Federal requirements are also intended by HHS to 

be implemented flexibly in relation to the individual characteristics of the organization. 

The Role of the CLAS Standards in Guiding a National Agenda 

on Cultural Competence 

Ideally, the issuance of national standards for CLAS should result in the replacement of the 

patchwork of different definitions and requirements with one universally understood set of 

guidance. Experience from other fields demonstrates that health care organizations, providers, 

policymakers, and accreditation organizations benefit when expectations are clear yet flexible, 

resources for implementation are made available, and mechanisms for review and oversight are 

specific. Naturally, this is a process that takes place in the context of years of experimentation, 

adaptation, and refinement of the standards themselves. In the short term, it is a marker of 

success when the standards are used as models for improving policy and practice. Even before 

the publication of the final standards in the Federal Register, the draft standards have inspired 

and guided activity around cultural competence in a wide variety of contexts. 

Over the last few years, HHS has begun to integrate cultural and linguistic competence in an 

expanding number of important program rules and regulations. HCFA regulations for 

Medicare+Choice and Medicaid address cultural and linguistic competence, and cultural 

competence will be the focus of quality improvement projects under the Quality Improvement 

Office of Minority Health 33 
National Standards for CLAS in Health Car e 

System for Managed Care (QUISMC) in the coming fiscal year. Many aspects of the CLAS 

standards are reflected in the OCR Guidance on Limited English Proficiency, and the power of 

the guidance to affect provider behavior suggests that this will be an area of significant activity 

in the coming years. The Consumer Bill of Rights mentions a variety of consumer protections 

that are influenced by cultural and linguistic issues, and these protections have been 

considered in a variety of legislative and HHS initiatives. 

This wide range of efforts affects nearly every health care organization in the country, and is 

complemented by other efforts within HHS to quantify and provide direction on cultural 

competence. OMH is developing a survey of cultural competence activities by managed care 

organizations using the CLAS standards as a framework. HRSA’s Center for Managed Care 

has recently released model cultural competence purchasing specifications for Medicaid 

managed care based on the CLAS standards (online at [www.gwumc.edu/~chsrp] — under 

the Sample Purchasing Specifications link. The HRSA Office of Minority Health has just 

begun work on performance measures for cultural competence. 

Although the CLAS standards project team has not formally kept track of other efforts to use 

the standards, the project team has been made aware of initiatives by private providers, county 

health departments and State agencies to implement, adapt, or reference the draft CLAS 

standards in policy directives. Inspired in part by their participation in the development of the 

draft and final standards, the Joint Commission on Accreditation of Healthcare Organizations 

will be initiating surveyor education on cultural competence. We anticipate that these efforts 

will increase with the publication of the final standards in the Federal Register. 

A better understanding of the relationship between culturally competent health services and 

patient satisfaction/clinical outcomes/health status is needed, and these issues will be more 

fully explored in the forthcoming research agenda for CLAS, sponsored by OMH and the 

Agency for Health Research and Quality. Recently published studies reinforce the intuition 

that a lack of attention to cultural issues leads to less than optimal health care, and that 

addressing these concerns or using certain CLAS interventions leads to improved outcomes. 

This research does not exist for every population or every type of CLAS intervention—most of 

it is concentrated on the impact of language or communication barriers—but it is sufficient to 

suggest that additional work in this area is warranted. One might also consider innovative 

ways of looking at the existing literature for links between relevant factors that would support 

the concept of CLAS interventions. Brach (2000) and Betancourt (1999) both propose that 

one can “connect the dots” between studies on communication, patient satisfaction, adherence 

and health outcomes to demonstrate that attention to each element has an impact on the next, 

and a link between improved communication (the heart of most CLAS interventions) and 

improved health outcomes can convincingly be made. Nevertheless, as the discussion on the 

relationship between CLAS and outcomes continues, it is important to remember that the vast 

majority of health practices and protocols in use today are unsupported by research-based 

outcomes analysis. 

Further work on the relationship between culturally competent services and patient outcomes 

will also clarify concerns related to the costs and cost-benefits of CLAS. Risk management is 

sufficient incentive for some organizations that have experienced the results of inappropriate 

or unnecessary testing, clinical inefficiency, misdiagnosis, negative outcomes, and malpractice 

due to cultural and linguistic issues. The Mutual Insurance Corp of America sees enough of a 

34 U.S. Department of Health and Human Services 
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link between these factors and liability that it offers a discount on malpractice insurance to 

physicians who participate in cultural competence training (Trosty, 1998). But it is also 

conceivable that many health care organizations and policymakers will be uncomfortable with 

adopting standards for CLAS because implementation will involve spending money on the 

educational, staffing, and organizational changes required to make services more accessible. 

For example, in the Medicaid program, where significant numbers of ethnically diverse 

patients are receiving care, reimbursement has never been adequate for the cost of medical 

services. States may not allocate more resources to provide services of adequate quality in an 

appropriate manner, given the long history of unsuccessful legal and legislative maneuvers to 

enhance reimbursement for other reasons. 

The implementation of CLAS may be particularly challenging for private practitioners, 

community clinics, and public hospitals; the latter two already are struggling with large 

uncompensated care burdens. Accommodations will also have to be made when an 

organization is small or is in a rural or frontier area where cultural resources may be hard to 

come by. For such organizations, it may be valuable to consider offering government grants to 

implement networks of culturally competent services, or direct reimbursement from 

government for certain services (such as for interpreters in Washington State). But in the forprofit sector, whether through private insurance or in managed care contracts, these services 

should be considered the cost of doing business. Managed care organizations and other health 

care organizations should consider the ethics of collecting premiums or reimbursement for 

services that certain populations cannot use because they are ineffectively delivered or 

inaccessible. It is even worse to penalize consumers for inappropriately utilizing services 

because they cannot understand the rules for using them. 

It is increasingly common to hear health care organizations and analysts speak of the 

“business case” for addressing diversity. The trade literature in health care has witnessed an 

upsurge of articles on cultural and linguistic competence in the last three years, and the cited 

industry leaders come from around the country. In many areas, ethnic communities are an 

attractive target for marketing strategies because they represent an untapped “niche” in a tight 

health care market. Cambridge Health Alliance and the New York Downtown Hospital are 

two health systems that have harnessed the potential of culturally competent services to 

strengthen and satisfy their customer base. Other health care organizations, such as Kaiser 

Permanente and Harvard Pilgrim Health Care, have strategically addressed diversity issues 

because of the obvious demographic changes in their communities or because patient/staff 

satisfaction surveys demand greater attention to CLAS services. All these examples are 

characterized by efforts to integrate responsiveness to cultural and linguistic issues into the 

whole fabric of their operations, rather than just as a marketing add-on. 

Given the tremendous variations in organization type, local populations, resources and 

expertise, the path to culturally responsive health services will be different for every health 

care organization. The CLAS standards can provide a substantial framework for guiding 

implementation in a common direction, although the work does not end here. As the following 

recommendations for future action will attest, the standards are a necessary initial tool that 

must be buttressed by supportive experimentation, development, and research that will give 

stakeholders the full set of resources they need to improve their services to diverse 

populations. Out of this improved service delivery, we believe that culturally diverse 

Office of Minority Health 35 
National Standards for CLAS in Health Car e 

populations will benefit from increased access to health services, more appropriate utilization 

of those services, better clinical outcomes and, in time, decreased disparities in health status. 

RECOMMENDATIONS 

The underlying theme of feedback from public and expert comments was that health care 

organizations and providers need clear guidance on how to implement CLAS in health care 

settings. The standards themselves outline the basic activities that constitute a framework for 

organizational cultural and linguistic competence. The commentary and discussion 

accompanying each standard in the following section of this report provide further guidance. 

However, considerable challenges are posed by the lack of synthesis, standardization, 

consensus, or resources in many areas addressed by the standards. The following 

recommendations suggest actions that could be taken in the public and private sector to 

facilitate implementation of the CLAS standards by addressing the “gaps” in these areas. The 

recommendations are based on input from public comments and the NPAC, with additional 

insights from the project team. 

These recommendations are designed to stimulate the interest and support of a variety of 

policymaking, advocacy and funding agencies, including national health care organizations, 

local and national foundations, and local, state and Federal health agencies. Any work done 

in response to the recommendations should be collaborative and focused on building 

consensus and support among all key stakeholders in CLAS. 1 (See page 43 for footnote.) 

Culturally Competent Care 

Develop a consensus on core cultural competencies for clinicians, pr oviders and other staff 

members, and develop and validate measures for assessing these competencies in individuals. 

There currently is no agreement across health professional specialties on what specifically 

constitutes individual cultural competence or how it is best measured. Existing guides and 

assessment tools, although not scientifically validated, collectively provide a body of 

knowledge on cultural competency and its assessment in individuals. A synthesis of this 

knowledge and subsequent consensus-building efforts to establish core cultural competencies 

could provide the foundation for the development of cultural competency training programs 

and assessment measures. Validated assessment measures, in turn, could help organizations 

link the demonstration of cultural competence skills and behaviors to performance evaluations 

and staff rewards for their improvements. 

Conduct and disseminate research to connect cultural competency behaviors to specific health 

outcomes. 

Although some studies show that a lack of attention to cultural and linguistic issues is 

associated with less optimal health care, research has not yet fully explicated the relationship 

between culturally and linguistically competent health services and clinical outcomes/health 

status. Further work in this area could help build a convincing evidence base in support of 

CLAS interventions and clarify concerns related to the costs and cost-benefits of CLAS. OMH 

currently is funding a project to identify key research areas and questions related to CLAS and 

to propose a research agenda for future work in this area. 

36 U.S. Department of Health and Human Services 
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Support and increase national, state, and local efforts to expand the pool of health car e 

professionals who are from diverse communities. 

One of the major challenges to building a culturally diverse staff at all levels of an organization 

is the current lack of capacity within the workforce of health professionals, particularly 

clinical staff. Organizational efforts to recruit and “grow their own” diverse staff need to be 

reinforced at the national, state and local levels, and financial support for health professions 

students from disadvantaged backgrounds needs to be increased. Other activities in this area 

could include the establishment of a recruitment database of bilingual and bicultural health 

care practitioners and support for the development of pathways for foreign-trained health care 

professionals to receive credentialing and licensure in the United States. 

Develop a consensus on curricula standards and evaluative tools for cultural competency 

training for both clinical providers and nonclinical staff. 

In the absence of standardized curricula or universally accepted certification or credentialing 

for cultural competence, training programs and curricula vary widely. These variations, along 

with the lack of adequately validated assessment tools, make it difficult to evaluate or compare 

the effectiveness of cultural competence trainings. The development of curricula standards 

and evaluation tools would help organizations determine which training programs are most 

likely to foster cultural competence among their providers and staff. An example of current 

work related to this recommendation is the California Endowment’s funding of efforts to 

develop a consensus standard on cultural competency training. 

Cultural competency training should be substantively integrated into health pr ofessions 

education and training at all levels, both academic and functional. 

Currently, cultural competence education in academic settings varies widely, ranging from 

semester-long courses to a few hours of training. Collaboration among Federal agencies, health 

professions schools, state licensure bodies, and accreditation agencies could help ensure that 

cultural competency training is integrated into all phases of health professions education, 

including core curriculum, professional licensure, and continuing professional development 

programs. An example of work in the area addressed by this recommendation is the 

Association of American Medical Colleges’ (AAMC) recent approval of mandatory diversity 

accreditation requirements. 

Language Access Services 

Collect and disseminate information on model programs and strategies of implementing 

language assistance services. 

There is broad experience nationally in developing and managing language assistance services, 

and many informal networks of information-sharing and technical assistance exist to support 

the refinement of these models. These resources, including case studies, program summaries, 

and technical information, should be widely promoted to health care providers and state and 

national provider organizations. 

Office of Minority Health 37 
National Standards for CLAS in Health Car e 

Support direct and indirect financing of language assistance services at all le vels of health 

services delivery. 

In addition to facilitating equal access to publicly and privately available health services, 

language assistance services can be a critical diagnostic tool for health care providers working 

with individuals with LEP, and the services should be financially supported in the same way 

as other diagnostic procedures. Federal and State policymakers should support and implement 

direct reimbursement of interpretation and translation costs through the Medicare and 

Medicaid program, and private insurers should do the same for their commercial products. At 

a minimum, interpretation and translation services should be allowable for inclusion under 

administrative or other overhead reimbursement allowances. Grants or contracts for health 

care services provided by government agencies and foundations should also include the costs 

of interpretation and translation when funded services are of potential benefit to individuals 

with LEP. These services would include direct medical, mental health, substance abuse, health 

promotion, and related social services, as well as health education campaigns and participation 

in biomedical research or clinical trials. 

Support the development of national standards for medical and community interpreter 

training, skills assessment, certification and codes of ethics. 

This process could be facilitated by supporting current regional efforts in these areas, and 

convening a national group to develop national guidelines. 

Develop national standards or guidelines for the translation of health-related materials 

according to the principles laid out in Standard 7. Support the adoption of these standards by 

government agencies and health care organizations that purchase or produce materials in 

other languages. 

Develop standard language or templates for key documents used by many health car e 

organizations, such as consent forms, advanced directives, health information, and medication 

information. 

Such documents could be translated into a range of languages, and made available through the 

Internet for downloading and customization by individual providers. This could also be done 

within individual large agencies or health care organizations to streamline the process of 

producing such materials and greatly reduce associated costs. For example, Washington State 

Department of Social and Health Services has translated and electronically stores standard 

templates for dozens of commonly used documents. Slight alterations are made to customize 

each document for different recipients. 

Develop an Internet clearinghouse of downloadable sample translated documents de veloped by 

agencies around the country. 

Such a clearinghouse would be an excellent and highly cost-effective venture that could 

partner government agencies, foundations and national health organizations to reduce or 

eliminate the re-creation and duplication of effort to develop materials that already exist. 

Models for such an effort have been sponsored by a government health agency in Australia, 

38 U.S. Department of Health and Human Services 
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and a public-private partnership in Canada (see the discussion section of Standard 7 for more 

detail on these models). 

Organizational Supports for Cultural Competence 

Develop model implementation plan and toolkit for CLAS that includes model strategies, 

policies, and a phase-in timetable with checklists and measurable short-and long-term process 

goals. 

Health care organizations without much experience in designing or implementing CLAS 

services need guidance on where to start and what can be accomplished over a given 

timeframe. Based on the experience of other organizations that have implemented CLAS 

services, a customizable implementation plan and detailed toolkit would support the 

development of an organizational strategic plan and efficient implementation of services. The 

Heartland Alliance’s cultural competence toolkit for managed care organizations is one model 

of such a product that could be more closely tailored to the CLAS standards and expanded to 

address the needs and structures of other types of health care organizations. 

Expand the availability of centralized information on CLAS model programs and practices, 

with contacts, detailed resource information, and bibliographic references. 

Health care organizations frequently feel unable to begin work on CLAS because they are 

unaware of successful implementation models for each standard. A well-publicized 

clearinghouse of information would help organizations avoid reinventing the wheel or 

investing in strategies that have not proven their worth. This recommendation will be 

discussed in further detail in the general recommendations section below. 

Survey and disseminate information about model strategies to involve ethnic communities in 

the development and oversight of CLAS services. 

Designing structures and processes to meaningfully involve ethnic community representatives 

in the development and oversight of health services is an ongoing challenge for health care 

organizations. Community and migrant health centers have a long history of experience in this 

area, and many mainstream organizations have begun to develop community advisory 

committees and other mechanisms to facilitate this involvement. Surveying and analyzing the 

elements of successful and failed strategies of integrating community and consumer 

involvement in the design and delivery of CLAS services would be a useful resource for those 

working towards this goal. 

Conduct a critical review of current organizational self-assessment tools, and define baseline 

and ongoing organizational self-assessment processes for cultural and linguistic competence . 

Organizational self-assessment can help identify problems and develop strategies for improving 

delivery of CLAS. However, available tools for organizational self-assessment of cultural 

competence have not been validated against each other and often are not suited for every type 

of institution. Defining processes for conducting baseline and ongoing organizational selfassessment of CLAS-related activities will help organizations track their progress in 

implementing the CLAS standards. 

Office of Minority Health 39 
National Standards for CLAS in Health Car e 

Develop standard tools or processes for health care organizations to measure performance , 

satisfaction, and access related to CLAS. 

Integrating measures related to cultural and linguistic competence into existing quality 

improvement programs could help organizations learn whether CLAS delivery processes 

produce the desired results. However, no consensus on state-of-the-art measures of 

performance, satisfaction, and access related to CLAS currently exists. Developing standard, 

CLAS-related measurement tools or processes could help organizations link these measures 

with routine quality efforts, and could help build the evidence base regarding the impact of 

CLAS interventions on performance, patient satisfaction, and access. 

Federal, state, and accreditation agencies should develop and require standardized, uniform 

data sets related to the race, ethnicity, and language of their patients/consumers. 

The collection and analyses of race, ethnicity, and language data can help organizations 

provide CLAS to their patients/consumers and identify and track similarities and differences 

in performance and quality of care in ethnic, cultural, and geographic communities. However, 

one of the difficulties in analyzing these data is the wide variation of collection methodologies. 

Collaborative efforts among local, state, and Federal agencies to develop and require the use of 

uniform race, ethnicity, and language data sets would foster the sharing and broader use of 

these data and facilitate research and analysis. 

Develop best practices or methods to help health care organizations integrate race, ethnicity, 

and language data components into their data collection processes. 

Collecting data on race, ethnicity, and language is not yet a universal practice, and health care 

organizations have concerns about issues related to implementation and maintenance, 

confidentiality, and costs. Exploring lessons learned by organizations that have successfully 

integrated these data components into their data collection processes and developing a primer 

that explains identified best practices or methods could help other organizations overcome 

barriers to implementing CLAS Standard 10. 

Develop a guide to help health care organizations incorporate race, ethnicity, and language 

variables into routine outcomes analyses. 

In the process of conducting standard outcomes or risk management assessments, many health 

care organizations neglect to look at race, ethnicity, and language variables. As a result, they 

are unable to track health outcomes disparities associated with these variables or to make 

improvements in services based on quantifiable experience. Health care organizations would 

benefit from a guide outlining sample methodologies and examples from health care 

organizations already engaged in this work. 

Develop a framework or process for maintaining a culture-sensitive community pr ofile and 

needs assessment. 

Obtaining demographic, cultural, and epidemiological data on the racial and ethnic groups in 

the service area and identifying the health care needs and preferences of those groups can help 

health care organizations better understand and serve their diverse communities. However, 

40 U.S. Department of Health and Human Services 
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many organizations have neither the in-house capacity to maintain a community profile/needs 

assessment nor the resources to hire consultants to conduct this CLAS activity. Other 

organizations use standard public health frameworks to obtain information about their 

communities but do not yet collect data relevant to CLAS. The development of a framework or 

process that organizations can follow to obtain and analyze key elements of CLAS-related 

information on their community will foster implementation of Standard 11. For example, a 

national organization such as the Association of State and Territorial Health Officials, the 

National Association of City and County Health Organizations, or the U.S. Conference of 

Mayors could develop a strategy and tool for state and local health departments to collaborate 

with health care organizations in their area to centrally collect data relevant to community 

profiles and needs assessments (see the discussion section of Standard 11). 

Develop guidance for the human resources, legal and ethics staff or committees of health car e 

organizations on the impact and management of cross-cultural ethics issues. 

Health care organizations and clinicians are often faced with cultural and religious beliefs that 

may contradict standard clinical or institutional practices. For example, a family may have 

cultural reasons for not sharing a terminal diagnosis with a patient relative, or a patient may 

refuse to read and sign informed consent documents that outline potentially negative 

outcomes. An instructional problem-solving case-book and training program on cross-cultural 

conflict, ethical and legal issues, including model institutional processes and policies, should 

be developed and made widely available to staff who participate in resolving institutional 

ethical or legal conflicts. 

Develop reporting guidelines to help organizations share information with the public about 

efforts to implement the CLAS standards. 

Providing information about an organization’s progress toward implementing the CLAS 

standards can help an organization reach out to potential patients/consumers and educate staff 

about the cultural and linguistic competence goals of the organization. The information 

would also help community residents to understand and monitor the progress that the 

organization is making towards implementation of CLAS standards. Without reporting 

guidelines, however, every organization could have its own approach to evaluating its progress 

toward what it has defined as CLAS, and consumers will not be able to compare reported 

results from various health care organizations. The development of a common set of reporting 

requirements will enhance the comparability of reported information and the ability of 

consumers to make informed choices about their health care. 

General Recommendations on the Overall CLAS Standards Agenda 

In addition to recommendations listed above on the specific performance areas outlined in the 

CLAS standards, the public comments, the National Project Advisory Committee, and Project 

Team made recommendations on how to support implementation of the overall CLAS 

standards agenda. These recommendations are listed by general categories below. 

Raise awareness about and promote the adoption of the CLAS standards 

The CLAS standards should be disseminated and promoted widely to all key stakeholder 

groups identified in the Federal Register notice: providers, policymakers, accreditation and 

Office of Minority Health 41 
National Standards for CLAS in Health Car e 

credentialing agencies, purchasers, patients, advocates, educators, and the health care 

community in general. For example, national ethnic organizations should work with local 

affiliates and other community-based ethnic organizations to educate consumers about how to 

use the CLAS standards with local health organizations to make services more culturally and 

linguistically accessible. National and state health professional and health provider 

organizations should communicate with their constituencies about the standards through 

conferences, newsletters, journals, and electronic media. Health professions training 

institutions and organizations should incorporate information about CLAS into their training, 

curricula development, accreditation and licensing processes. Health care accreditation 

organizations and purchasers should all be targeted for awareness-raising efforts that suggest 

how representatives of these stakeholder groups can integrate the CLAS standards into their 

own goals. A national coalition with representatives of multiple stakeholder groups should be 

formed to advocate for changes in health care delivery, payment and policymaking arenas 

around CLAS. 

HHS should formally adopt the standards, through regulation and program guidance, for all 

Federally funded health programs. State health agencies should also consider adopting the 

standards for their own agencies as well as for health care services for which they contract 

with public and private providers. The standards should be incorporated into the standards 

and performance measures of key national accrediting organizations such as the Joint 

Commission on Accreditation of Health Care Organizations and the National Committee on 

Quality Assurance, as well as state licensing and accrediting bodies. Individual health care 

provider organizations should also consider adopting the CLAS standards into their missions 

and strategic plans. 

Support the development and dissemination of resources and technical assistance on CLAS 

implementation 

Develop a national clearinghouse of information on the implementation of CLAS. Such a 

resource, which ideally would be internet based, could include information about model 

programs; assessments of different approaches, techniques and tools; evaluations of and links 

to other information sources, and interactive forums for individuals to share information and 

resources with each other. Such a clearinghouse should coordinate and enhance, not 

duplicate, existing Internet and physical sources of information about cross-cultural health 

care. 

Support the development and dissemination of specific resource needs, such as model 

interpreter and cultural competence training, standard translation techniques, community 

involvement strategies, performance measures, etc. 

Coordinate and support the delivery of technical assistance specifically on CLAS, building on 

the efforts of other technical centers, such as the OMH Resource Center and the National 

Center for Cultural Competence. This technical assistance could be delivered free or on a 

sliding scale fee-base through telephone, e-mail, conferences, and on-site training. 

Support assessments, evaluations, and oversight on implementation of the CLAS standards 

Conduct pilot tests on the implementation of CLAS by health care organizations to determine 

42 U.S. Department of Health and Human Services 
PART I


the feasibility of different approaches, assess the impact of implementation on organizational 

behavior, and document an experience base that can be used in other settings. 

Support the development of a variety of tools that would facilitate the assessment, evaluation, 

and monitoring of CLAS activities by health care organizations. Standardized tools for self 

assessments, and measuring performance would help these organizations track their own 

progress in implementing CLAS, and assist outside agencies with evaluating and comparing 

performance over time and between similar types of health care organizations. 

Support research on the impact of CLAS interventions on health care outcomes, including the 

identification of key questions, data sets, researchers, and funding for such research. 

Dissemination of the results of such research will aid providers and policymakers who need a 

stronger evidence base on the value of CLAS to support their implementation activities or 

policymaking. OMH is currently supporting the development of a CLAS research agenda to 

provide guidance on these issues. 

Next steps 

Track the implementation and adoption of the CLAS standards by different types of health 

organizations around the country. An internet-based clearinghouse of this information would 

facilitate the ability of health care organizations to learn from and build on the experiences 

rather than recreate the wheel. It would also assist researchers and policymakers who want to 

track and evaluate the progress of CLAS implementation. This could be developed as a part of 

the national CLAS clearinghouse recommended above or separately. 

Analyze the data collected about CLAS implementation experience to document trends, best 

practices, and lessons learned. Such an evaluation would support future revisions of the CLAS 

standards. 

The CLAS Standards should be reviewed, revised, and reissued on a periodic basis by a 

national task force of experts, potentially modeled after the US Preventive Services Task Force. 

[http://www.ahcpr.gov/clinic/uspsfact.htm]. This group could review the evidence base on 

implementation activities, the results of outcomes-related research, and could make 

recommendations to key stakeholders that would further the CLAS standards development 

and implementation agenda. 

1 For additional recommendations suitable for state and local organizations and funders, readers are directed to the 

summary of recommendations contained in the Multicultural Health Best Practices Overview prepared by Resources 

for Cross Cultural Health Care for The California Endowment and available online at [www.diversityrx.org/best]. 

Office of Minority Health 43 

PART II: INDIVIDUAL STANDARDS WITH DISCUSSION


PART II


INDIVIDUAL STANDARDS WITH DISCUSSION 

INTRODUCTION 

Part II presents the final national standards on culturally and linguistically appropriate 

services (CLAS) in health care as they appeared in the Federal Register on December 22, 2000 

(Volume 65, No. 247, pages 80865 to 80879). Each standard is accompanied by a brief 

commentary (also published in the Federal Register) that provides additional clarification of 

key issues or requirements. Because these commentaries are crucial to the understanding of 

their respective standards, it is intended that they not be separated from the CLAS standards 

in executive summaries or other abbreviations of the full CLAS report. 

In addition, Part II includes discussion sections that further explicate the intent, current 

practice and research, and/or potential implementation strategies or issues for each standard. 

Some of the material in the discussions has been gleaned from the public comment and NPAC 

review processes, which produced a rich store of information, suggestions, and opinions about 

the context, implementation, and implications of the CLAS standards1. Also included is 

material that was originally reported in Assessing Cultural Competence in Health Care: 

Recommendations for National Standards and an Outcomes-Focused Research Agenda 

(Fortier and Taylor, 1999), which was published at the end of the first phase of the CLAS 

standards project. The length of each discussion section reflects the availability of relevant 

research, policy, public comments, and reported practices and, thus, should not be construed 

as indicative of the relative importance of a particular standard. 

The full complement of public comments on the CLAS standards is available on the OMH Resource Center Web site 

[http://www.omhrc/clas]. 

Office of Minority Health 47 

1 

PART II


STANDARD 1 

CULTURALLY COMPETENT HEALTH CARE (GUIDELINE) 

Standard and Commentary 

1. Health care organizations should ensure that patients/consumers receive from 

all staff members effective, understandable, and respectful care that is provided in 

a manner compatible with their cultural health beliefs and practices and 

preferred language. 

This standard constitutes the fundamental requirement on which all activities specified in the 

other CLAS standards are based. Its intent is to ensure that all patients/consumers receiving 

health care services experience culturally and linguistically competent encounters with an 

organization’s staff. The standard is relevant not only to staff, who ultimately are responsible 

for the kinds of interactions they have with patients, but also to their organizations, which 

must provide the managers, policies, and systems that support the realities of culturally 

competent encounters. 

Respectful care includes taking into consideration the values, preferences, and expressed needs 

of the patient/consumer. Understandable care involves communicating in the preferred 

language of patients/consumers and ensuring that they understand all clinical and 

administrative information. Effective care results in positive outcomes for patients/consumers, 

including satisfaction; appropriate preventive services, diagnosis, and treatment; adherence; 

and improved health status. 

Cultural competence includes being able to recognize and respond to health-related beliefs and 

cultural values, disease incidence and prevalence, and treatment efficacy. Examples of 

culturally competent care include striving to overcome cultural, language, and communications 

barriers; providing an environment in which patients/consumers from diverse cultural 

backgrounds feel comfortable discussing their cultural health beliefs and practices in the 

context of negotiating treatment options; using community workers as a check on the 

effectiveness of communication and care; encouraging patients/consumers to express their 

spiritual beliefs and cultural practices; and being familiar with and respectful of various 

traditional healing systems and beliefs and, where appropriate, integrating these approaches 

into treatment plans. When individuals need additional assistance, it may be appropriate to 

involve a patient advocate, case manager, or ombudsperson with special expertise in crosscultural issues. 

Ways to operationalize this standard include implementing all the other CLAS standards. For 

example, in accordance with Standard 3, ensure that staff and other personnel receive crosscultural education and training, and that their skills in providing culturally competent care are 

assessed through testing, direct observation, and monitoring of patient/consumer satisfaction 

with individual staff/personnel encounters. Assessment of staff and other personnel could also 

be done in the context of regular staff performance reviews or other evaluations that could be 

included in the organizational self-assessment called for in Standard 9. Health care 

organizations should provide patients/consumers with information regarding existing laws 

and policies prohibiting disrespectful or discriminatory treatment or marketing/enrollment 

practices. 

Office of Minority Health 49 
National Standards for CLAS in Health Car e 

Discussion 

Intent of the Standard 

Although the fourteen CLAS standards as a whole articulate the many different activities that 

constitute an organization’s cultural and linguistic competence, this first standard focuses on 

the heart of the issue—ensuring that all staff interact with patients/consumers in a way that is 

culturally appropriate. The standard is inextricably linked to Standards 2 and 3 because the 

two principal actions an organization can take to foster culturally competent interactions are 

to recruit and retain a diverse staff and to ensure that all staff members receive ongoing 

education and training in CLAS delivery. The National Health Law Program emphasized the 

intent of this standard in its public comments, noting that “this overarching and 

comprehensive standard is crucial to creating a safe and welcoming environment for the entire 

patient population and sending a message of appreciation for the diversity of patients, as well 

as setting an appropriate tone for the organization. If the patient feels comfortable with the 

provider, she or he will more freely communicate with the provider and, consequently, be a 

more informed patient.” One physician commented that by increasing their cultural diversity 

and competence and making their patients feel comfortable about receiving health care, 

providers would be able to focus better on health disparities in minority populations and thus 

decrease a major health economic issue in the United States. 

Definition and Assessment of Individual Cultural and Linguistic Competence 

There are many definitions of cultural competence, and several similar terms that are used in 

the literature, including cultural appropriateness, cultural awareness, cultural responsiveness, 

and cultural sensitivity. The various definitions of cultural competence that are articulated by 

laws, organizations, and academics represent diverse perspectives and address different needs. 

A broad vision is offered by Lavizzo-Mourey and Mackenzie and includes being able to 

recognize and respond to health-related beliefs and cultural practices, disparities in disease 

incidence and prevalence, and differences in treatment efficacy. The meaning of cultural and 

linguistic competence that is stated in the preamble constituted the working definition used in 

the development of the CLAS standards and is adapted from definitions developed by Cross et 

al (1989). This definition was chosen because it is the most broadly applicable across all of an 

organization’s staff. Providing care in a manner that is compatible with the 

patient’s/consumer’s cultural health beliefs and practices and preferred language, as stated in 

the standard itself, is a distillation of key elements of cultural and linguistic competence that 

apply to all members of an organization’s staff. 

Although there is no universal agreement on what specifically constitutes cultural and 

linguistic competence in an individual or how it is best measured, there are many guides and 

tools available to assist health care providers. These are discussed in more detail in the 

discussion section of Standard 3. In general, practitioners must strive to develop the following: 

• attitudes that are open-minded and tolerant of social and cultural differences; 

• interpersonal behaviors that convey concern and respect, in spite of any differences; 

• a commitment to continually increase personal knowledge of the impact of culture on 

health, in addition to specific knowledge about the communities being served; and 

50 U.S. Department of Health and Human Services 
PART II


• skills that allow providers to respectfully elicit and respond constructively to relevant


personal and cultural issues from patients/consumers during the clinical interview.


Individuals should also strive to deepen their own cultural self awareness as well as their 

knowledge of and sensitivity to the historical/collective experiences of racial and ethnic groups 

that have experienced racism, prejudice, bias, and other forms of discrimination in the health 

care system and society in general. 

Effective, Understandable, and Respectful Care 

Effective health care is care that successfully restores the patient/consumer to the desired 

health status and takes steps to protect future health by incorporating health promotion, 

disease prevention, and wellness interventions. According to one health services researcher, 

“not only would it predictably and reliably cure the patient and increase his or her wellbeing, 

but it would be available, acceptable, affordable, free of adverse effects, easy to administer, 

readily amenable to quality control measures, compatible with other necessary health and 

social interventions, and, for good measure, it would increase job satisfaction in the health 

professional who delivers and monitors it” (Greenhalgh, 1998). In order for health services to 

have a chance of being effective in a patient, the clinician must accurately diagnose the illness, 

discern the correct treatment for that individual, and negotiate the treatment regimen 

successfully with the patient. These steps can all be affected by linguistically and culturally 

mediated factors that have an impact on trust, open communication, and adherence to 

treatment plans. There is also an increasing evidence base that suggests that ethnic, racial, and 

ethnopharmacological differences in how patients respond to treatments may vary the 

effectiveness of one approach over another. 

Understandablecare focuses on the need for patients/consumers to fully comprehend 

questions, instructions, and explanations from clinical, administrative, and other staff. It 

relates to populations that have limited proficiency in English as well as diverse Englishspeaking groups who may still have problems understanding the health care system and 

medical terminology. Understandable care encompasses not only addressing language 

differences and ensuring linguistic comprehension but also explaining technical or specialized 

terminology and concepts and verifying that the patient/consumer understands the content of 

what is being said. 

Respectmay appear to be implied by cultural competence, but it does not always appear in the 

literature as an essential component of culturally competent care. However, respectful care is 

an important factor in creating an environment in which patients/consumers from diverse 

backgrounds feel comfortable discussing their specific needs with any member of an 

organization’s staff. The Consumer Bill of Rights and Responsibilities states that “Consumers 

have the right to considerate, respectful care from all members of the health care system at all 

times and under all circumstances. The Bill of Rights cites one definition of respect (Faden 

and Beauchamp, 1986) as recognizing “a person’s capacities and perspectives, including his or 

her right to hold certain views, to make certain choices, and to take certain actions based on 

personal values and beliefs.” An environment of mutual respect is essential to maintain a 

quality health care system. The American Nurses Association’s Nursing’s Code of Ethics sets 

the goal of providing services with “respect for human dignity and the uniqueness of the 

client, unrestricted by considerations of social or economic status, personal attributes, or the 

nature of health problems.” Along with being nonjudgmental and sensitive to the needs of 

Office of Minority Health 51 
National Standards for CLAS in Health Car e 

each individual, staff and organizations can provide respectful care by treating 

patients/consumers as full partners in the planning and delivery of health care services, as 

stated in Standard 12. Other actions that communicate respect include preserving 

patients’/consumers’ dignity during physical examinations, giving emotional support to 

alleviate their fears and anxieties, taking their complaints seriously, and respecting their time 

by avoiding lengthy waiting room delays and inadequate time with doctors. 

Traditional Healing Systems and Beliefs 

Integral to the provision of culturally competent health care services is familiarity with and 

respect for the traditional healing systems and beliefs of diverse cultural groups. The World 

Health Organization defines traditional medicine as approaches to protecting and restoring 

health that existed before the arrival of modern medicine. Traditional systems generally have 

had to meet the needs of local communities for many centuries. Many of the complementary 

and alternative medical practices that are becoming more popular in the United States— 

including acupuncture, botanicals, and massage and therapeutic touch—have their roots in 

traditional medicine. Culturally competent providers ask about and understand the traditional 

healing practices used by their patients/consumers and integrate these traditional approaches 

into treatment plans when appropriate. Staff and organizational openness toward and respect 

for traditional healing practices and traditional healers is an important element in making 

patients/consumers from culturally diverse backgrounds feel comfortable within a western 

medical setting and may contribute toward better adherence to treatment plans. 

Cultural and Linguistic Competence Among All Staff 

Although cultural and linguistic competence measures and training often focus on clinicians, 

the intent of this standard is to ensure that all members of an organization’s staff exhibit the 

set of behaviors, skills, and attitudes that enables effective work in cross-cultural situations. 

Having staff members who are not culturally and linguistically sensitive at initial points of 

contact (e.g., admissions) could result in culturally diverse patients/consumers being excluded 

from services or feeling unwelcome and leaving the facility before they can be seen by clinical 

staff. Public comments provided many examples of caregivers who do not consider themselves 

“staff” and thus not subject to the terms of such a standard; staff members who self-identify 

themselves as culturally competent without understanding the criteria for this quality; and 

staff or administrators who believe that treating all patients/consumers alike, or “equally,” 

constitutes cultural competence. Organizations should recognize that although hiring 

community workers and cultural brokers can be an important way to enhance culturally 

competent care, it does not diminish the responsibility of all providers and other staff members 

to be culturally competent. Finally, this standard applies not only to staff providing services in 

direct medical care settings but also to staff in all care settings, including those who serve 

people seeking public health or preventive services. 

52 U.S. Department of Health and Human Services 
PART II


Organizational Role in Ensuring Culturally Competent Encounters 

Although the nature of interactions with patients/consumers ultimately depends on staff 

members, organizations must support culturally and linguistically competent encounters by 

providing the necessary supervision and infrastructure. Organizations must become familiar 

with the communities they serve and understand the characteristics and specific perspectives 

of the cultural groups represented (see Standard 11). Organizations must use this information 

about the communities to design services that meet the unique and general health care needs 

of their service area. The organizational role includes working with physicians and other care 

providers to build cultural information into day-to-day interactions with patients/consumers; 

making available culturally appropriate diagnostic tools, clinical guidelines, and health 

education materials; and requiring ongoing education and training on CLAS delivery (see 

Standard 3). Organizations also need to design services that are accessible to diverse 

populations (e.g., by staffing and scheduling bilingual and culturally knowledgeable nurses to 

give advice on call centers, considering longer visits for patients/consumers who have complex 

linguistic or cultural needs; and building larger exam and waiting rooms in facilities where 

multiple family members are involved in supporting patients seeking health care). The 

organization’s management should be responsible for assessing the cultural and linguistic 

competence skills of staff members in performance evaluations and monitoring patient 

satisfaction with staff encounters. 

Office of Minority Health 53 
National Standards for CLAS in Health Car e 

STANDARD 2 

STAFF DIVERSITY (GUIDELINE) 

Standard and Commentary 

2. Health care organizations should implement strategies to recruit, retain, and 

promote at all levels of the organization a diverse staff and leadership that are 

representative of the demographic characteristics of the service area. 

The diversity of an organization’s staff is a necessary, but not sufficient, condition for 

providing culturally and linguistically appropriate health care services. Although hiring 

bilingual individuals from different cultures does not in itself ensure that the staff is culturally 

competent and sensitive, this practice is a critical component to the delivery of relevant and 

effective services for all patients/consumers. Diverse staff is defined in the standard as being 

representative of the diverse demographic population of the service area and includes the 

leadership of the organization as well as its governing boards, clinicians, and administrative 

personnel. Building staff that adequately mirrors the diversity of the patient/consumer 

population should be based on continual assessment of staff demographics (collected as part of 

organizational self-assessment in accordance with Standard 9) as well as demographic data 

from the community maintained in accordance with Standard 11. Staff refers not only to 

personnel employed by the health care organization but also its subcontracted and affiliated 

personnel. 

Staff diversity at all levels of an organization can play an important role in considering the 

needs of patients/consumers from various cultural and linguistic backgrounds in the decisions 

and structures of the organization. Examples of the types of staff members whose backgrounds 

should reflect the community’s diversity include clinical staff such as doctors, nurses, and 

allied health professionals; support staff such as receptionists; administrative staff such as 

individuals in the billing department; clergy and lay volunteers; and high-level decisionmakers 

such as senior managers, corporate executives, and governing bodies such as boards of 

directors. 

Acknowledging the practical difficulties in achieving full racial, ethnic, and cultural parity 

within the workforce, this standard emphasizes commitment and a good-faith effort rather 

than specific outcomes. It focuses not on numerical goals or quotas, but rather on the 

continuing efforts of an organization to design, implement, and evaluate strategies for 

recruiting and retaining a diverse staff as well as continual quality evaluation of improvements 

in this area. The goal of staff diversity should be incorporated into organizations’ mission 

statements, strategic plans, and goals. Organizations should use proactive strategies, such as 

incentives, mentoring programs, and partnerships with local schools and employment 

programs, to build diverse workforce capacity. Organizations should encourage the retention 

of diverse staff by fostering a culture of responsiveness toward the ideas and challenges that a 

culturally diverse staff offers. 

54 U.S. Department of Health and Human Services 
PART II


Discussion 

The Value of Diversity in an Organization 

There is research evidence that suggests that many culturally diverse patients/consumers 

frequently prefer to choose providers of the same gender, racial or ethnic background, and 

language. Some managed care Medicare/Medicaid contracts address this issue of provider 

choice by calling for two providers from the racial or ethnic background of the patient. 

Comments on the CLAS standards included a description of one organization’s market survey, 

which found that language is more important to its patients/consumers than ethnicity. In 

either case, a bilingual, bicultural staff is more likely to be sensitive to cultural issues, and be 

better able to facilitate direct communication with patients/consumers in whose language staff 

members are proficient. On an organizational level, it is easier to understand and address the 

needs of the diverse population groups being served when staff includes members who come 

from those groups. Moreover, a culturally and linguistically diverse staff can help create an 

environment that can make patients/consumers feel more comfortable and welcome. 

Yet the value of diversity goes beyond the potential benefits of “like serving like.” Diversity 

facilitates the development and maintenance of a culturally and linguistically competent 

organization, a more complex and far-reaching goal. To accomplish this goal, diversity needs 

to be embraced consistently throughout the organization, with each person at every level of 

the organization understanding it as a philosophy and a required practice. Diversity needs to 

be grounded in the organization’s identity and addressed in its strategic plan and mission 

statement. Staff members with different cultural backgrounds can yield a variety of ideas and 

decisions that are attuned to the perceptions, motivations, and needs of patients/consumers 

and can help translate the needs of increasingly diverse communities into effective messages, 

educational materials, programs, and services. Staff diversity also enhances an organization’s 

ability to attract, retain, educate, and motivate employees. Valuing staff diversity can enable an 

organization to deliver better services to its patients/consumers and, hopefully, contribute to 

the eventual elimination of racial and ethnic disparities in health. 

Importance of Diversity Among All Staff 

Being responsive to the needs of diverse patients/consumers is essential not only at the service 

level but also at the strategic planning, evaluation, and decision-making levels. Thus, cultural 

diversity must exist throughout the entire staff of an organization. If most of the staff 

reflecting diverse populations in the community is employed only in lower level positions, an 

organization may meet certain state or contractual requirements but not be truly diverse. 

Diversity among staff providing direct services in support, outreach, or clinical roles is 

important but not sufficient. Diversity is needed throughout the hierarchy of an organization, 

including leadership levels such as senior management, chief executives, and board of 

directors. This can promote strategic planning, as well as policy and decision making, that are 

inclusive of the cultural and linguistic needs of all patient/consumer populations. Bicultural 

and bilingual staff at all levels is both a sign of an organization’s cultural and linguistic 

competence, and a motivating force to make the organization’s services increasingly relevant 

and effective for its patients/consumers. 

Office of Minority Health 55 
National Standards for CLAS in Health Car e 

In addition to applying vertically throughout the hierarchies of an organization’s staff, this 

standard also must be applied horizontally across various contractual relationships. Many 

health care organizations use networks or affiliated providers to deliver services to their 

patients/consumers. A hospital clinic may subcontract with a group of critical care physicians 

to provide emergency services. Because such situations are becoming more prevalent, it is 

important that staff diversity encompass all individuals involved in health care delivery, 

whatever their contractual or subcontractual relationship with the organization. 

Strategies to Build Workforce Capacity 

One of the major challenges to building a staff that truly reflects the community being served 

at all levels is the shortage of diverse capacity within the workforce of health professionals, 

particularly clinical staff. Students from diverse cultural groups remain dramatically 

underrepresented among enrollees and graduates of schools of medicine, public health, 

nursing, and other health professions. Culturally and linguistically diverse health professionals 

who earned their degrees abroad often face difficulties obtaining licensure and certification in 

this country. The health care industry is facing increasing shortages of bilingual, bicultural 

professionals in the available workforce, and health care organizations must compete not only 

among themselves but also with other industries. This trend makes it difficult to build a staff 

that adequately mirrors the cultural diversity and broad range of languages that could be 

encountered within a patient/consumer population. Nevertheless, organizations can design, 

implement, and evaluate strategies that will help them recruit and retain a more diverse staff. 

Recruitment 

Collaborations are an important aspect of strategies to recruit diverse staff and build workforce 

capacities. Improved linkages between academic and service settings can help identify 

potential recruits already in the educational “pipeline.” For example, organizations can work 

with local universities, medical and allied health schools and federally qualified health centers 

to provide community-based internships, residencies, rotations, and fellowships that focus on 

preparation for serving culturally diverse populations. Organizations could become involved 

with summer employment, college recruitment, or mentoring programs to provide direct 

learning experiences for younger students who may be interested in health careers or working 

with diverse populations. Public comments on the CLAS standards emphasized the need for 

health care organizations to learn about existing grassroots efforts and to build partnerships 

with community-based organizations, including organizations that provide services to 

immigrants and refugees. Because true organizational commitment to diversity is a major 

incentive for bilingual and bicultural job applicants, a genuine commitment to, and active 

participation in, partnership activities are crucial to attracting candidates. 

Incentives are another approach to recruiting bilingual, bicultural staff. Comments suggested 

that organizations offer salary bonuses or differentials to staff who are bilingual; provide 

incentives such as salary bonuses to staff who achieve cultural competence or interpreter 

certification; and support programs such as the National Health Service Corps, which provides 

incentives to primary care physicians who practice in underserved communities. 

Organizations attempting to reach a more diverse group of candidates need to find alternatives 

to generic newspaper advertisements, search firms, and other mainstream recruiting methods. 

Community-based and national ethnic health organizations and networks as well as 

56 U.S. Department of Health and Human Services 
PART II


publications and search firms that target diverse populations may provide better channels for 

recruiting and advertising vacancies. 

“Grow Your Own” Staff 

Although community members can add valuable knowledge about language and culture to 

clinical expertise, they often are asked to do so on a volunteer basis. Organizations can build 

their staff diversity by helping people from various cultural backgrounds complete preliminary 

and advanced training for positions at many different levels. “Grow your own” programs hire 

individuals from the community and provide them with training to act as interpreters and 

cultural brokers. These liaison staff members are encouraged to pursue formal training for a 

health profession or other important roles in the organization. This approach helps advance 

the careers of workers who already are committed to their community. The role of community 

health workers also can be expanded, with proper training, to include mulitfunctional roles in 

bridging the gap between mainstream organizations and ethnic and other cultural 

communities. For example, community advisors selected as representatives of the various 

cultural groups served by an organization can educate staff about the needs and concerns of 

their communities, in addition to acting as interpreters, translators, health educators or case 

managers. 

Many health care organizations sponsor bilingual and bicultural individuals for training to 

interpret in clinic settings and act as outreach workers in the community. The health 

promoters (“promotores”) model has been used successfully, especially in the Latino 

community, to create a pool of fluent and knowledgeable bilingual health workers in their own 

community. Structured training, internships, and apprenticeships can help community 

members with little or no knowledge of health issues learn communication and leadership 

skills and build careers in bilingual outreach and education. One potential source of 

interpreters suggested in public comments is the recipients of Temporary Aid for Needy 

Families (“TANF”), who could be trained by county job training programs to be bilingual 

interpreters as a step towards self-sufficiency. 

Retention 

Recruiting staff from different cultural and linguistic backgrounds is only one step toward the 

goal of staff diversity. Retention of staff with bilingual or bicultural skills is another major 

challenge for organizations, which frequently experience high turnover of diverse staff. 

Organizations need to monitor work assignments and hire sufficient personnel to ensure that 

bilingual/bicultural staff members are not “burnt out” by inappropriate or excessive demands. 

For example, employees who can speak a foreign language of a predominant ethnic group 

should not be overburdened with demands for interpretation services if not explicitly a part of 

their job description and responsibilities. Organizations should also avoid using non-clinical 

support staff inappropriately in cultural broker positions without sufficient training. 

Organizations need to guard against having a “glass ceiling” by ensuring that diverse staff 

members get promoted into administrative or managerial positions where their cultural and 

linguistic capabilities can make unique contributions to planning as well as policy and decision 

making. In academic settings, an institution’s system of merit raises and promotions should 

not penalize staff whose involvement with cultural competence activities such as mentoring or 

Office of Minority Health 57 
National Standards for CLAS in Health Car e 

community liaison programs reduce their availability for traditionally valued work such as 

research. Organizations also need to foster an environment that respects the differences and is 

responsive to the challenges that a culturally diverse staff brings into the workplace. 

58 U.S. Department of Health and Human Services 
PART II


STANDARD 3 

STAFF EDUCATION AND TRAINING (GUIDELINE) 

Standard and Commentary 

3. Health care organizations should ensure that staff at all levls and across all 

disciplines receive ongoing education and training in culturally and linguistically 

appropriate service delivery. 

Hiring a diverse staff does not automatically guarantee the provision of culturally competent 

care. Staff education and training are also crucial to ensuring CLAS delivery because all staff 

will interact with patients/consumers representing different countries of origin, acculturation 

levels, and social and economic standing. Staff refers not only to personnel employed by the 

health care organization but also its subcontracted and affiliated personnel. 

Health care organizations should either verify that staff at all levels and in all disciplines 

participate in ongoing CME- or CEU-accredited education or other training in CLAS delivery, 

or arrange for such education and training to be made available to staff. This training should 

be based on sound educational (i.e., adult learning) principles, include pre- and post-training 

assessments, and be conducted by appropriately qualified individuals. Training objectives 

should be tailored for relevance to the particular functions of the trainees and the needs of the 

specific populations served, and over time should include the following topics: 

• Effects of differences in the cultures of staff and patients/consumers on clinical and other 

workforce encounters, including effects of the culture of American medicine and clinical 

training; 

• elements of effective communication among staff and patients/consumers of different 

cultures and different languages, including how to work with interpreters and telephone 

language services; 

• strategies and techniques for the resolution of racial, ethnic, or cultural conflicts between 

staff and patients/consumers; 

• health care organizations’ written language access policies and procedures, including how 

to access interpreters and translated written materials; 

• applicable provisions of Title VI of the Civil Rights Act of 1964, 42 U.S.C. §2000d, 45 

C.F.R. §80.1 et seq. (including Office for Civil Rights Guidance on Title VI of the Civil 

Rights Act of 1964, with respect to services for (LEP) individuals (65 Fed. Reg. 52762­

52774, August 30, 2000); 

• health care organizations’ complaint/grievance procedures; 

• effects of cultural differences on health promotion and disease prevention, diagnosis and 

treatment, and supportive, rehabilitative, and end-of-life care; 

• impact of poverty and socioeconomic status, race and racism, ethnicity, and sociocultural 

factors on access to care, service utilization, quality of care, and health outcomes; 

• differences in the clinical management of preventable and chronic diseases and conditions 

indicated by differences in the race or ethnicity of patients/consumers; and 

Office of Minority Health 59 
National Standards for CLAS in Health Car e 

• effects of cultural differences among patients/consumers and staff upon health outcomes, 

patient satisfaction, and clinical management of preventable and chronic diseases and 

conditions. 

Organizations that conduct the trainings should involve community representatives in the 

development of CLAS education and training programs, in accordance with Standard 12. 

Discussion 

Education and Training in CLAS 

Staff education and training may be the single most important element of assuring the cultural 

and linguistic competence of an organization and is closely related to improving clinical care 

and outcomes as addressed in Standard 1. The Consumer Bill of Rights and Responsibilities 

suggests that organizations can enhance patient participation in treatment by arranging for 

“continuing education courses for providers to assure cultural and language competency,” and 

that patients’ right to respect and nondiscrimination can be fostered by developing education 

and training programs that address “the significance of cultural attitudes on the effectiveness 

of health care.” The Association of American Medical Colleges (AAMC) has approved 

mandatory diversity accreditation requirements, and legislation is being proposed in some 

states to require questions related to cultural competence on board examinations. It was 

suggested in one public comment that cultural competence training should be viewed as an 

essential part of patient care, on par in importance with training in treatment methods for 

medical care. 

Currently, there is no consensus on the definition of cultural competence in individuals nor 

what constitutes a culturally competent health professional. Moreover, there are no standard 

curricula or universally accepted certification or credentialing for cultural competence, and no 

standardized measures for evaluating the effectiveness of cultural competence trainings. But 

there are many options available for organizations to ensure that their staff receives cultural 

competence training. Some organizations may find it easier to verify staff compliance by 

offering or arranging for the training themselves. Organizations may hire an external 

consultant to conduct in-service training or use in-house personnel who have sufficient 

expertise in developing and delivering cultural competence curricula. Smaller community 

organizations might be able to pool resources with neighboring organizations to conduct joint 

trainings. This standard deliberately allows organizations flexibility in how they ensure the 

ongoing education and training of their staff in CLAS delivery. 

Recipients of Training 

As one public comment noted, hiring a diverse staff may increase trust in a health care 

organization, but it does not automatically establish cultural competence. Commenters gave 

many examples of how similar ethnicity or language alone does not equate with being 

culturally competent. A hospital in a primarily African-American community in Baltimore 

might think it sufficient to have African-American doctors on staff. However, within the 

African-American community there are many different subcommunities. An AfricanAmerican doctor who sees a Haitian patient may not understand many of the cultural beliefs 

and traditional medical practices within the Haitian community. All staff, regardless of 

cultural background, need to receive training in cultural competence. Every staff member will 

60 U.S. Department of Health and Human Services 
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encounter individuals whose age, cultural traditions, religious and health beliefs, and 

educational and socioeconomic status differ from his or her own. 

For the same reasons that diversity is needed at all levels of an organization to foster cultural 

competence, staff members from managerial to front-line personnel also need ongoing training 

in CLAS delivery. All providers—including physicians, nurses, psychiatrists, nutritionists, and 

social workers—should receive basic and continuing education in cultural competence. This 

includes providers in training, who can be targeted for cultural competence education in 

academic settings, as well as more established providers, who received their health professions 

training when there was little awareness of CLAS. Thus, continuing education courses that 

train currently practicing providers should be emphasized. Nonclinical staff members for 

whom continuing education courses are not required still need to receive basic and ongoing 

training in cultural competence issues to improve their ability to interact sensitively and 

respectfully with patients/clients of different cultures. 

Curricula and Training Programs 

In the absence of a standard curriculum for cultural competence, widely varying training 

programs and curricula abound. This lack of uniformity makes it difficult to evaluate or make 

recommendations about existing programs or to develop replicable model curricula. Ideally, 

training and skills assessment should be integrated from the earliest phases of health 

professions training through the professional licensing process. Several public comments cited 

the need to incorporate cultural competence training into curriculum and continuing 

education requirements and for agencies such as the Office of Minority Health to collaborate 

with health professions schools, state licensure bodies, and accreditation agencies on this 

issue. Currently, cultural competence education in academic settings ranges from semesterlong courses to discrete components that are part of a broader course outline. One public 

comment reported that many nursing and medical schools currently have no more than a 2- or 

3-hour segment of their entire training devoted to cultural competence. However, in addition 

to the new AAMC requirement, other steps are being taken to address the issue. Curriculum 

guidelines for teaching culturally sensitive and competent health care to primary health care 

residents have been developed by the Society of Teachers of Family Medicine and several 

schools of nursing have developed cross-cultural nursing programs. 

Outside academic settings, cultural competence may be addressed in continuing education 

courses for staff that range from a few hours to a few days. Public comments emphasized that 

cultural competence education and training should be ongoing to counter the effects of staff 

turnover and the natural tendency for new behaviors to be extinguished when not reinforced. 

Ongoing training also recognizes that cultural competence is a process in which staff members 

are made aware of their limitations, given knowledge and skills, and then provided with 

opportunities to practice what they have learned by interacting with people of different 

cultures. Some comments suggested that training programs should be CME- and/or CEUaccredited whenever possible. Such accreditation will help assure that the training program 

meets applicable minimum requirements by state medical associations regarding content, 

hours, and trainer credentials. CME- and CEU-accredited training also requires records of 

attendance and each participant’s evaluation of the program. Organizations have found that 

clinical attendance increases when training programs are CME- and CEU-accredited because 

such trainings assist clinicians in meeting their licensure or relicensure requirements. 

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Conferences and workshops on cultural competence topics offer supplemental ways to convey 

skills, resources, and training. For example, meetings could be designed to address cultural 

competence issues related to a particular health care setting (e.g., community health clinic), 

ethnic group (e.g., Hmong women), or health disparity (e.g., diabetes in Native Americans). 

Public comments provided examples of approaches to teaching cultural competence that use 

community-based organizations, hands-on experiences, and opportunities for learning from 

patients as well as other staff members. 

Curricula content and approach usually depend on the preferences of the trainer and, thus, 

vary widely. Whereas some trainings focus on how to eliminate prejudice or value differences, 

others present theories of cross-cultural health, or general information on specific cultural 

groups. For example, a common method of teaching cultural competence is to provide a general 

overview of the role of culture in health service delivery, and then to spend time focusing on 

the health beliefs and behaviors of specific ethnic groups. While this approach has the effect of 

increasing general knowledge about an ethnic population, it can lead to facile stereotyping if 

improperly conducted or understood. It has been debated that incorporating a more universal 

skills approach to cultural competence allows practitioners to use general questioning and 

medical history-taking techniques on any individual from any ethnic background (e.g., 

Kleinman, 1978; Berlin, 1982). This approach could be more useful in health facilities that see 

a wide diversity of clientele and could be combined with intensive education about specific 

ethnic groups. 

Several comments emphasized the importance of conducing staff training needs assessments, 

and one recommendation called for focus groups to uncover specific issues that affect how 

staff members interact with different patient groups. Some comments indicated that providers 

prefer training that is customized to their specific responsibilities, issues, organization, and 

patient/consumer populations. Thus, training for a children’s hospital in a Latino community 

should target Latino pediatric issues. Along with credentialing requirements, customized 

content and the provision of practical tools are key strategies to encourage staff to participate 

in cultural competence education and training. Although organizations that conduct their own 

trainings will have control over content and approach, all organizations should ensure that key 

topics are addressed over the course of ongoing trainings. Not every element of cultural 

competence education and training can be prescribed, but the topics suggested in the 

standard’s commentary focus on a set of knowledge and skills that will enable staff to deliver 

basic CLAS within the organizational setting. 

Cultural Competence Trainers 

Although trainers and consultants play a major role in educating and training health 

professionals in CLAS delivery, their credentials in this area may vary widely. Some 

individuals have completed doctoral level research and academic training on cross-cultural 

issues such as medical anthropology or transcultural psychology; others rely on previous 

experience in human resources diversity training; and others have no formal training at all. 

Public comments suggested that some well-meaning cultural competence trainers are teaching 

their own biases and that it is important to assure that curriculum developers and trainers 

have sound credentials and relevant experience. However, there is no national consensus on 

what these credentials and experience should be, although there are increasing numbers of 

degrees, courses, and programs specifically designed to qualify individuals to be cultural 

62 U.S. Department of Health and Human Services 
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competence trainers. At least one state university has begun offering a master’s degree 

program in diversity training, and some organizations are “growing” their own trainers by 

supporting this kind of graduate education for their employees. Until credentials or 

certification programs for cultural competence trainers are established, an organization can try 

to identify qualified individuals by checking their references, observing them conduct a 

training session, and reviewing any evaluative information on the short- and long-term impact 

of their training. Comments also suggested that using CME-accredited trainings is one way to 

hold trainers to a standard. 

Assessment of the Impact and Validity of Trainings 

Several comments recommended pre- and post-training self-assessments of trainees as one 

means to evaluate the impact of cultural competence trainings. However, neither comments 

nor the literature present any consensus on what constitute valid and appropriate selfassessment tools and performance measures. At the least, pre- and post- training selfassessments should indicate whether an individual has absorbed the content of the training. It 

is more useful to know, in the short term, whether participants have incorporated knowledge 

and skills from the trainings into their daily practice and, in the long term, whether such 

behavior changes have affected patient/consumer satisfaction or outcomes. Harvard Pilgrim 

Health Care uses post-training videotapes of model patient-provider interactions to assist with 

the behavioral interpretation of how well clinicians have incorporated their training. 

Comments also suggested that linking the demonstration of cultural and linguistic competence 

skills and behaviors to performance evaluations and pay increases could help reward staff for 

their development in this area. 

Many assessment tools have been developed and reviewed by researchers and agencies, but 

they have not been rated against each other or validated. A review of the measurement and 

assessment literature conducted by Estrada (1999) indicated that many available tools are 

questionnaires that presumably ask valid and representative questions about cultural 

competence and solicit answers that presumably reflect reliable and accurate information 

about respondents’ assessment of cultural competence services. Yet no empirical evidence 

shows whether these measures are valid (i.e., representative of the construct of cultural 

competence) or reliable (i.e., provide accurate information about cultural competence). 

Moreover, it remains difficult and time-consuming to find assessment tools that are 

appropriate for particular organizations or circumstances. Independent and objective analyses 

of such resources are difficult to find because information is often spread by word-of-mouth, 

and organizations tend to promote their own tools and approaches. Researchers continue to 

develop and test new tools that are promising but not without limitations. Until selfassessment tools are adequately validated, it will remain difficult to determine and compare 

the effectiveness of cultural competence education and training programs. 

Community Involvement in Training 

Although input from public comments generally favored basic standards for curricula and 

trainers, there were many reminders that cultural competence trainings ultimately must fit the 

needs of the community. Consequently, an important aspect of cultural competence training is 

considering the role that local communities will have in training activities. For organizations 

that conduct their own trainings, the involvement of community representatives from the 

earliest stages of planning will help curriculum developers and trainers understand the needs, 

Office of Minority Health 63 
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culture, and views of people the organization is serving. Community input can serve a dual 

purpose in strengthening training programs. First, it can provide information such as specifics 

about relevant health issues, language nuances, and health beliefs and practices. Just as 

important, it can provide concrete feedback on how patients/consumers perceive and react to 

the organization and its staff. Comments suggested that involving community organizations in 

the development of training programs also could help identify local funding sources and 

facilitate any data collection (e.g., patient satisfaction surveys) that the organization intends to 

link to the trainings. 

64 U.S. Department of Health and Human Services 
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STANDARD 4 

QUALFIED LANGUAGE ASSISTANCE SERVICES (MANDATE) 

Standard and Commentary 

4. Health care organizations must offer and provide language assistance services, 

including bilingual staff and interpreter services, at no cost to each 

patient/consumer with limited English pr oficiency at all points of contact, in a 

timely manner during all hours of operation. 

Standards 4, 5, 6, and 7 are based on Title VI of the Civil Rights Act of 1964 (Title VI) with 

respect to services for limited English proficient (LEP) individuals. Title VI requires all 

entities receiving Federal financial assistance, including health care organizations, take steps to 

ensure that LEP persons have meaningful access to the health services that they provide. The 

key to providing meaningful access for LEP persons is to ensure effective communication 

between the entity and the LEP person. For complete details on compliance with these 

requirements, consult the HHS guidance on Title VI with respect to services for (LEP) 

individuals (65 Fed. Reg. 52762-52774, August 30, 2000) at [www.hhs.gov/ocr/lep]. 

Language services, as described below, must be made available to each individual with limited 

English proficiency who seeks services, regardless of the size of the individual’s language 

group in that community. Such an individual cannot speak, read, or understand the English 

language at a level that permits him or her to interact effectively with clinical or nonclinical 

staff at a health care organization. (Patients needing services in American Sign Language 

would also be covered by this standard, although other Federal laws and regulations apply and 

should be consulted separately.) 

Language services include, as a first preference, the availability of bilingual staff who can 

communicate directly with patients/consumers in their preferred language. When such staff 

members are not available, face-to-face interpretation provided by trained staff, or contract or 

volunteer interpreters, is the next preference. Telephone interpreter services should be used as 

a supplemental system when an interpreter is needed instantly, or when services are needed in 

an unusual or infrequently encountered language. The competence and qualifications of 

individuals providing language services are discussed in Standard 6. 

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Discussion 

There have been numerous anecdotal and research-based accounts of how language barriers 

negatively affect the ability of a person with limited English proficiency to benefit from health 

care services. When these barriers go unaddressed, patients can be harmed because critical 

health information was not properly communicated. By contrast, research evidence 

demonstrates that patients are more satisfied and adhere better to treatment when language 

assistance is provided. In addition to these clinical and ethical reasons for providing language 

assistance, the Office for Civil Rights (OCR) guidance on persons with LEP thoroughly states 

the civil rights case for doing so. 

Language assistance strategies and model programs 

Health care organizations may use a wide spectrum of strategies for overcoming linguistic 

barriers to health care. These strategies include the use of bilingual providers, 

bilingual/bicultural community health workers, and interpreters (onsite and telephone). 

Certain strategies may work best in a particular health care setting, while others have wide 

application and can be useful in all settings—the best programs frequently use a combination 

of approaches. An overview of these strategies can be found in “Overview of Models and 

Strategies for Overcoming Linguistic and Cultural Barriers to Health Care” 

[http://www.diversityrx.org/HTML/MODELS.htm]. Despite concerns from many health care 

providers that addressing language barriers is difficult and expensive, there are many model 

programs nationwide at community health centers, health departments, hospitals, and 

managed care organizations. A few examples of some of these programs should give a sense of 

the approaches a health care institution can take. 

Among smaller volume health care organizations, such as community health centers and 

health departments, the most frequently used options are bilingual staff, and staff or volunteer 

interpreters who may also have other job responsibilities. Many of these organizations also use 

or run community interpreter services, which can offer a wide variety of different languages 

to many providers in a community at competitive rates. It is essentially a shared resource that 

allows many providers to access contract interpreters, especially from small language groups, 

when hiring them individually would be prohibitively expensive. Many Seattle area hospitals 

turned to a community-based interpreter service for their initial response to language 

discrimination complaints, and inaugurated the Hospital Interpreter Program. Similar 

community services have been started by university-based programs (e.g. Language Link of 

Worchester, Massachusetts and Community Health Connect of Northern Virginia), immigrant 

services agencies (e.g. Catholic Charities of San Diego, California, and the Heartland Alliance 

of Chicago, Illinois), health departments, and community clinics (e.g. Asian Health Services of 

Oakland, California). These programs have a qualitative advantage over telephone interpreter 

services in that they offer in-person, local ethnic community expertise at lower rates, and their 

interpreters are trained specifically for medical settings. These programs have the added bonus 

of creating jobs and career paths for immigrants and refugees. 

Some of the most exciting and sophisticated programs of interpreter services in health care 

settings exist at a select group of hospitals and health care systems in different parts of the 

country. Massachusetts and the Seattle area are noted for having the highest density of 

interpreter services among hospitals in their regions. Exceptional model programs also are 

66 U.S. Department of Health and Human Services 
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found at the University of California-Davis, Stanford University Hospital, Santa Clara Valley 

Medical Center, and Cedars-Sinai Medical Center in California. Other notable programs have 

been developed in Oregon, Minnesota, Illinois, and Florida. Characteristics of these model 

programs (which may provide more than 50,000 interpreted encounters per year) include: an 

organization-wide commitment to develop, staff, and fund formal interpreter programs with 

administrative staff and in-house or contract interpreters; 24-hour access to onsite interpreters 

or telephone backup services; computerized tracking of patient language characteristics (as 

called for in Standard 10), interpreter scheduling, and utilization; formal assessment of 

interpreter skills and/or training; program evaluation; and advocacy from clinical staff to 

administrators on the need to maintain a trained interpretation staff adequate to meet patient 

demand. 

Perhaps the most challenging setting in which to successfully bridge language barriers is the 

network or multi-facility managed care organization (MCO). The sheer numbers of providers 

and facilities, combined with an ethnically diverse and geographically dispersed client base, 

makes the replication of other model practices or programs organizationally challenging. 

Nevertheless, many MCOs are attempting to tackle the problem in a variety of ways: 

• Alameda Alliance for Health(AAH) is a network public Medicaid managed care plan that 

was developed to serve Alameda County, California. It provides interpreter services for 

clinical visits through a community language bank that trains and certifies interpreters, 

with a telephone language line back-up. The plan uses its provider newsletters to promote 

the use of interpreters. To overcome provider resistance to using interpreters, AAH is 

planning to pay an increment for visits for which interpreters are used. This policy has 

been budgeted, but was not yet implemented as of August, 2000. 

• Amerigroup Corporationis a plan that serves only urban populations in New Jersey, 

Illinois, Texas, Maryland, and Washington, DC. It uses a network of interpreters 

credentialed through a process similar to the one used to credential its provider network. 

To minimize the amount of wait time, the plan uses two (rather than one) telephone 

language lines as back-up. Every provider goes through an orientation which includes 

information on how to access free interpreter services. Amerigroup also gives providers a 

card with the number to access interpreter services 24-hours a day/seven days a week, and 

publishes information in a newsletter on interpreter availability. Amerigroup arranges 

and pays for the interpreter services used by providers. Usually the enrollee calls member 

services, and the plan arranges for the interpreter services in advance of the provider 

appointment. 

• Kaiser Permanente (KP)-Southern Californiaactively recruits and attempts to deploy 

bilingual health professionals at facilities where demand is greatest. It also offers a pay 

differential for bilingual staff who serve as interpreters and have passed a proficiency 

exam. The KP-San Francisco medical center offers interpretation and translation in 37 

languages and dialects. The majority of the 20,000 per year face-to-face interpreter 

appointments are prescheduled, and 95 percent of interpreter staff are trained through a 

community college health care interpreter certificate program. KP-San Francisco has also 

implemented language preference fields in their member database, and established a 

Chinese interpreter call center to support the Northern California region’s appointments 

and advice call center with more than 45,000 telephone interpreting encounters per year. 

Office of Minority Health 67 
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These organizations each take a slightly different approach to meeting language needs, and it 

is likely that a combination of strategies would be the most flexible and comprehensive 

solution. This combination could include: a bilingual provider roster; in-house or contract 

interpreters who could be deployed for appointments with specialists or other non-bilingual 

providers; bilingual/bicultural “case managers” to handle member services calls, appointments, 

health education visits, and other non-clinical encounters; and network agreements with 

hospitals and other facilities that have in-house language capacity. The greatest difficulty 

would probably remain with free-standing contract pharmacy, laboratory and other diagnostic 

facilities that typically do not offer language services. These institutions could use the MCO’s 

contract telephone interpreter services. 

Telephone Interpreter Services 

As noted in the discussion of Standard 6, both the OCR guidance and the National Health 

Law Program (NHeLP) report speak to using telephone interpreter services as a supplemental 

system, because such services may not always have readily available interpreters who are 

familiar with medical terminology or concepts. Nevertheless, telephone interpretation may be 

the only option in facilities that are very decentralized (such as plans based on an independent 

physician network), or must deal with a large number (25 or more) of languages, for which it 

would be difficult to maintain an adequate staff. In general, face-to-face encounters between 

patients/consumers and clinicians that involve diagnosis, treatment, and education may 

benefit from an on-site interpreter and, if lengthy, may be significantly cheaper that using a 

phone service. On-site interpreters are also able to observe and raise issues indicated by 

demeanor or body language from the patient—an especially critical ability when sensitive 

information is being communicated. Telephone interpretation may be appropriate for 

nonclinical interactions, emergency situations when waiting for an in-person interpreter may 

compromise patient outcomes, or situations requiring very uncommon languages. Staff should 

have clear written policies on when it is acceptable to use telephone interpreter services, and 

when in-person interpretation is necessary. Health care organizations should have standards 

by which they evaluate the quality of the services received, and have criteria to select high 

quality vendors. They should evaluate the recruitment and training programs used to select 

and train phone interpreters. If phone interpreters are used at all, procedures and policies 

should be in place to facilitate the use of these phone lines, and staff should be trained in their 

use. 

Cost of Interpreter Services 

There were a significant number of comments expressing concern about the financial 

implications of needing to provide language assistance services, especially interpretation. 

Comments representing home health agencies and small practice physicians receiving 

Medicare or Medicaid reimbursement felt that the cost of telephone or in-person 

interpretation services was frequently more expensive than the reimbursement they received 

for the office visit. Small community clinics and larger institutions are also concerned about 

the costs of interpreter programs, either because their overall budgets are fairly restricted, or 

the potential volume of demand is so large and diverse. These concerns have considerable 

merit, and reimbursement for interpretation and translation is an issue that Federal, state, and 

private insurance purchasers need to take seriously. As one doctor noted, interpretation for a 

non-English speaking patient/consumer is as important a diagnostic tool, or more so, than any 

blood test or x-ray. If medical diagnostic procedures are paid for, then interpretation services 

68 U.S. Department of Health and Human Services 
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should be similarly reimbursable. Washington State is one of the few States to reimburse for 

interpreter services under Medicaid. The Health Care Financing Administration in August 

2000 sent a letter to state Medicaid directors advising them that under both the State Child 

Health Insurance Program (SCHIP) and Medicaid programs, “Federal matching funds are 

available for States’ expenditures related to the provision of oral and written translation 

administrative activities and services provided for SCHIP or Medicaid recipients. Federal 

financial participation is available in state expenditures for such activities or services whether 

provided by staff interpreters, contract interpreters, or through a telephone service” 

[http://www.hcfa.gov/medicaid/smd83100.htm]. 

In the absence of reimbursement, all health care providers and organizations should consider 

the hidden costs of not bridging language barriers for patients. Individual physicians should 

consider the ethical and malpractice risks of treating patients/consumers with whom they 

cannot communicate. Health care organizations should also consider these issues, and should 

examine the costs of many ad hoc approaches, such as taking highly paid bilingual 

professionals away from clinical work to do interpretation, canceling scheduled surgical 

procedures because a patient did not understand the pre-operative instructions, or caring for 

much sicker individuals in the emergency room because patients had been unable to 

communicate with the appointments clerk in the primary care department. Jacobs found that 

the implementation of interpreter services at a New England health organization increased the 

use of preventive and other clinical services, such as the number of office visits, prescriptions 

written and filled, and receipt of flu shots, rectal exams, and fecal occult blood testing (Jacobs, 

2000). 

In light of cost-related concerns, it is interesting to note that the model programs described 

above were not spontaneously conceived, accepted, or maintained. Almost all these programs 

were started in response to Title VI discrimination complaints filed by LEP individuals that 

led to reviews and corrective consent agreements between the HHS Office for Civil Rights and 

the facility. Language services can be increasingly expensive to maintain as ethnic diversity in 

a community increases. Nevertheless, attempts to cut back programs are frequently met with 

vocal resistance from clinical staff who have come to rely on and respect trained interpreter 

assistance, and are unwilling to risk treating patients without it. 

Office of Minority Health 69 
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STANDARD 5 

NOTICES TO PATIENTS/CONSUMERS OF THE RIGHT TO LANGUAGE 

ASSISTANCE SERVICES (MANDATE) 

Standard and Commentary 

5. Health care organizations must provide to patients/consumers in their preferred 

language both verbal offers and written notices informing them of their right to 

receive language assistance services. 

LEP individuals should be informed—in a language they can understand—that they have the 

right to free language services and that such services are readily available. At all points of 

contact, health care organizations should also distribute written notices with this information 

and post translated signage. Health care organizations should explicitly inquire about the 

preferred language of each patient/consumer and record this information in all records. The 

preferred language of each patient/consumer is the language in which he or she feels most 

comfortable in a clinical or nonclinical encounter. 

Some successful methods of informing patients/consumers about language assistance services 

include: a) using language identification or “I speak . . .” cards; b) posting and maintaining 

signs in regularly encountered languages at all points of entry; c) creating uniform procedures 

for timely and effective telephone communication between staff and LEP persons; and d) 

including statements about the services available and the right to free language assistance 

services in appropriate non-English languages in brochures, booklets, outreach materials, and 

other materials that are routinely distributed to the public. 

Discussion 

Notices of Rights to Language Assistance 

It is frequently a challenge for individuals with LEP to access interpreter/bilingual services, 

even when an institution organizes and offers the services. One large hospital in California 

with a million dollar interpreter services program and more than 30,000 encounters per year 

still only serves a portion of the population that needs language assistance. A former 

interpreter services coordinator estimated that perhaps 30 percent of all patients who needed 

an interpreter did not get one, most likely because staff were too busy to make a request to the 

interpreter services office. This hospital’s experience shows that the availability of services is 

no guarantee that they will actually be used when the need arises. And without information 

about such services, many LEP individuals would not think or would be hesitant to ask a 

provider to supply an interpreter. 

Facilities around the country have developed innovative ways to publicize the availability of 

bilingual/interpreter services. At the University of Massachusetts Medical Center in 

Worchester, the staff at the main informational kiosk direct incoming LEP patients to a sign 

on the wall that has tear-off cards in many different languages. The patients select the 

appropriate card for their language and hand it to the staff person, who then contacts 

interpreter services. At the Pacific Medical Center Clinics in Seattle, Washington, all new 

patients are automatically assigned an interpreter in their birth language. The interpreter 

70 U.S. Department of Health and Human Services 
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appears at each visit unless the first visit reveals that interpreter services are unnecessary. In 

general, health care organizations should make available signs and notices about language 

assistance services at all major points of entry and discharge in a facility. They should also be 

present at different stations, departments, or offices where patients/consumers must regularly 

interact with staff, such as the pharmacy, laboratories, emergency room triage, and billing 

offices. 

Several community-based organizations publish bilingual wallet cards that inform the holder 

and any provider who receives it that the bearer of the card is LEP and entitled to interpreter 

services under state and Federal laws. The cards are distributed to individuals through 

community-based organizations and the carriers are instructed to present the card when 

seeking health services. The National Health Law Program reports that OCR voluntary 

compliance agreements with health care providers have required outreach to communities to 

publicize the availability of no-cost programs and services in non-English community 

newspapers and on radio and television stations, and to give notice to community agencies 

and referral sources about the facility’s language access policies and services (Perkins, 1998). 

Many providers, especially managed care organizations, have found that advertising the 

availability of bilingual services can increase enrollment from targeted communities. 

State and Federal laws, regulations, and contracts with health providers should reiterate, in 

detail, the Title VI provider obligation to inform recipients of their right to receive no-cost 

interpreter/bilingual services. Accreditation standards and measures should reflect and refer 

to relevant Federal laws, including Title VI. Oversight agencies and advocates can check 

compliance by entering facilities to see whether appropriate signage and notices are posted, 

and by calling facilities to inquire about availability of interpreters/bilingual staff. Staff should 

be instructed in the organization’s Title VI and other legal responsibilities and institutional 

procedures for securing interpreter/bilingual assistance so that they can respond promptly to a 

need for language assistance that might be generated by signage or notices to 

patients/consumers. 

Office of Minority Health 71 
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STANDARD 6 

QUALIFICATIONS FOR BILINGUAL AND INTERPRETER SERVICES 

(MANDATE) 

Standard and Commentary 

6. Health care organizations must assure the competence of language assistance 

provided to limited English proficient patients/consumers by interpreters and 

bilingual staff. Family and friends should not be used to provide interpretation 

services (except on request by the patient/consumer). 

Accurate and effective communication between patients/consumers and clinicians is the most 

essential component of the health care encounter. Patients/consumers cannot fully utilize or 

negotiate other important services if they cannot communicate with the nonclinical staff of 

health care organizations. When language barriers exist, relying on staff who are not fully 

bilingual or lack interpreter training frequently leads to misunderstanding, dissatisfaction, 

omission of vital information, misdiagnoses, inappropriate treatment, and lack of compliance. 

It is insufficient for health care organizations to use any apparently bilingual person for 

delivering language services—they must assess and ensure the training and competency of 

individuals who deliver such services. 

Bilingual clinicians and other staff who communicate directly with patients/consumers in 

their preferred language must demonstrate a command of both English and the target language 

that includes knowledge and facility with the terms and concepts relevant to the type of 

encounter. Ideally, this should be verified by formal testing. Research has shown that 

individuals with exposure to a second language, even those raised in bilingual homes, 

frequently overestimate their ability to communicate in that language, and make errors that 

could affect complete and accurate communication and comprehension. 

Prospective and working interpreters must demonstrate a similar level of bilingual proficiency. 

Health care organizations should verify the completion of, or arrange for, formal training in 

the techniques, ethics, and cross-cultural issues related to medical interpreting (a minimum of 

40 hours is recommended by the National Council on Interpretation in Health Care). 

Interpreters must be assessed for their ability to convey information accurately in both 

languages before they are allowed to interpret in a health care setting. 

In order to ensure complete, accurate, impartial, and confidential communication, family, 

friends or other individuals, should not be required, suggested, or used as interpreters. A 

patient/consumer may choose to use a family member or friend as an interpreter after being 

informed of the availability of free interpreter services unless the effectiveness of services is 

compromised or the LEP person’s confidentiality is violated. The health care organization’s 

staff should suggest that a trained interpreter be present during the encounter to ensure 

accurate interpretation and should document the offer and declination in the LEP person’s 

file. Minor children should never be used as interpreters, nor be allowed to interpret for their 

parents when they are the patients/consumers. 

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Discussion 

Qualified versus Unqualified Interpretation 

The provision of medical interpretation services in the United States is marked by contrasts: 

highly trained and well-paid professional interpreters deliver services in some communities, 

whereas other institutions use housekeeping staff who barely understand English or call 

ethnic restaurants for free, ad hoc ”interpretation.” A number of comments, including those 

received from major health care organizations, demonstrated a lack of understanding about the 

critical importance of competence and training in medical interpretation. Competence in 

medical interpretation means different things to different people. “Professional” can simply 

mean “paid.” “Trained” and “certified” may not mean trained or certified in medical 

interpretation, which requires a different set of skills, ethical considerations and, most 

importantly, technical language, than court or conference interpretation (which are the focus 

of the majority of training/certification programs). 

The research of Downing and others on the impact of using untrained interpreters makes 

clear that the error rate of untrained “interpreters” (including family and friends) is 

sufficiently high as to make their use more dangerous in some circumstances than no 

interpreter at all. Using untrained interpreters lends a false sense of security to both provider 

and client that accurate communication is actually taking place. In a close analysis of one 

encounter between a nurse practitioner, a Russian-speaking patient, and his son acting as 

interpreter, Downing uncovered 49 miscommunications by the “interpreter” in a conversation 

of only 25 exchanges of information. For example, 

• the interpreter misinterpreted (five times) because of lack of understanding of particular 

words and idioms; 

• the interpreter’s failure to interpret the question led the patient to try to guess what the 

question was and attempt an answer (four times); 

• the interpreter failed to interpret an answer offered by the patient (six times); 

• the interpreter seriously distorted the message in the process of interpreting it, by adding 

information (twice), omitting information (four times), or changing the meaning (seven 

times); 

• the reply that the nurse practitioner received from the patient through the interpreter was 

the answer to a different question than the one she had asked, but she did not know it 

(two times). 

This example dramatically illustrates the potential of misdiagnosis, inappropriate treatment, 

and liability when using unqualified individuals to interpret. (Downing, 1991) 

Interpreter Role, Skills Assessment, and Certification 

Assuring quality in an interpreted encounter depends on using commonly accepted definitions 

of role, interpreter training, and competency. Health care organizations need to use clear and 

consistent role definitions and practice standards to ensure the harmonious integration of 

interpreters into a clinical or administrative encounter. Staff members who work with 

interpreters need to know what interpreters do, what they do not do, and where responsibility 

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lies for different aspects of communication (this information is an essential training topic 

discussed in Standard 3 and a requirement of the OCR guidance). Medical interpreters are 

now working to clarify the definition of the medical interpreter role and to specify practice 

standards and codes of ethics. Pioneering work by the Massachusetts Medical Interpreter 

Association (MMIA) on practice standards for medical interpreters has provided a foundation 

for discussion and adoption of standards by other interpreter groups nationally. The MMIA 

standards address issues of interpreter skill, behavior, linguistic and cultural knowledge, and 

ethics. These standards of practice were based on extensive research, focus groups with 

working interpreters, and a formal analysis of a wide sample of practicing interpreter job 

responsibilities. The National Council on Interpretation in Health Care (NCIHC), which has 

been meeting since 1994 to discuss and move towards consensus on role and practice issues, 

has formally endorsed the MMIA standards. Another group, organized through the American 

Society for Testing and Materials, will soon release national standards for general 

interpretation, including specific guidelines for medical interpretation. 

Because the practice of using interpreters is still largely ad hoc in many settings, health care 

organizations frequently pay little attention to the skills and competency of any given 

individual called on to interpret. Because there are so few “formally” trained medical 

interpreters, the issues of skills assessment and training are often addressed simultaneously. 

When skills and competency are addressed, each organization typically uses its own 

instrument to test individuals who may be selected or hired as interpreters. Assessing 

competency is critical to assuring quality, and standardized tests for medical interpreting skill 

and language competency can give providers a necessary tool in this process. 

Developing standard tools for assessing basic medical interpreter skills is one component of 

implementing certification for interpreters. There has been increasing interest in developing 

both national and state level certification programs; in fact, the MMIA is developing a 

certification process for Massachusetts, and working collaboratively with other organizations 

to develop certification programs in California and New York, and nationally with NCIHC. 

Washington State already uses a certification process for medical and social service programs. 

Certification is ideally an endpoint in a continuum that includes widespread consensus about 

role definition, practice standards, standardized curriculum elements, and standardized 

competency assessments. While much progress has been made in each of these areas, 

additional development and dissemination, and the convening of a national discussion to seek 

consensus is necessary. Some medical interpreters propose addressing these issues on a stateby state basis. But given the intensive effort needed to properly develop these elements of the 

continuum, this process could be inefficiently replicated without much standardization for 

many years. One possibility is to define a minimum level of language proficiency and basic 

interpreter skills necessary to not compromise patient care. Additional roles and levels of 

responsibility could be added with additional training and achievement in higher levels of 

testing. This graduated approach would address some of the concerns expressed on behalf of 

community-based interpreters from smaller ethnic groups (i.e. Cambodian, Hmong, Somali) 

that may have few potential interpreter candidates, many of them without formal education or 

training opportunities. 

74 U.S. Department of Health and Human Services 
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Medical Interpreter Training 

If potential candidates for interpreter positions are not certified or do not pass a basic skills 

assessment, some health care organizations may test individuals for the ability to successfully 

complete interpreter training and then send them for training. Some health care institutions 

sponsor interpreter assessment and training services in-house; others collaborate with or refer 

to programs at local colleges or community organizations. Training programs can be difficult 

to initiate if qualified trainers are not available locally. In such cases, it is often advantageous 

for several institutions to pool resources and collaboratively establish a local or regional 

training program, using one of the many models of training already in existence. This 

collaborative structure can also be expanded over time to house a community-based pool of 

interpreters who could be shared and deployed among many provider organizations. A 1998 

document available online [http://www.ahschc.org/traindir2.htm] catalogues selected 

interpreter training programs in the U.S. and Canada that take a variety of approaches. The 

NCIHC has written that 40 hours of basic training seem to be average among well-regarded 

training programs. Essential topics include instruction in interpretation skills and techniques; 

ethics of interpreting in health care encounters; a review of key medical terminology, basic 

clinical concepts, and the workings of the American medical system; an overview of the role of 

culture and how to manage cultural issues; and professional interpretation issues. 

Bilingual Staff 

With respect to using bilingual staff as interpreters, it can not be assumed that a nurse, 

medical student, or other staff (clinical or not) who speaks two languages will be sufficiently 

familiar with medical terms and concepts in both languages. Bilingual individuals, unless they 

were trained as health professionals in another country, generally only have conversational 

skills in the target language, and medical terminology would need to be specifically acquired 

through a course of study. In addition, a bilingual individual may not have had formal training 

in medical interpreting skills, and may risk making the kinds of mistakes identified by 

Downing. 

These concerns can also arise when assumptions are made about “bilingual” staff or health 

professionals who communicate directly with LEP patients. These individuals may have 

learned the language conversationally at home, in high school, or in college, but lack training 

in medical terminology and concepts. Almost universally, the level of true bilingual ability is 

never ascertained. Kaiser Permanente of Southern California has instituted competency 

testing for staff who wish to operate in a bilingual or interpreter capacity. But many provider 

organizations rely heavily on lists of untested bilingual staff for both direct patient care and 

interpreting, and increasing numbers of managed care organizations market their services to 

LEP communities by highlighting their lists of bilingual health professionals. The presence of 

these lists may not be indicative of true language access because the individuals on them may 

not always be available or qualified to act in a bilingual or interpreter capacity. 

The notion of teaching health professionals another language for the purposes of diagnosis 

and treatment is controversial. Health care organizations and health professions training 

programs often encourage “survival Spanish” or other quick and/or intensive language courses 

as a means of preparing for, or coping with, the increasing numbers of LEP 

patients/consumers. While these courses may enhance basic communication and rapport with 

LEP individuals, they pose a serious danger by leading clinicians to believe they can 

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adequately communicate through the breadth and depth required of complex clinical 

encounters. A study conducted at Stanford University found that medical residents who took 

a 45-hour course in medical Spanish still made a considerable number of mistakes in 

communicating with patients who only spoke Spanish. Many of the mistakes could have had 

an impact on diagnosis or treatment (Prince, 1995). Linda Haffner, in her 1992 article 

Translation is Not Enough, reports many instances of physicians who thought they had a 

sufficient command of the language but, in fact, understood their patients incorrectly or made 

replies that were confusing, incorrect, or insulting (Haffner, 1992). The Downing research 

also suggests that using insufficiently bilingual health professionals can have the same negative 

impact as using interpreters of unknown skill. 

Nevertheless, language training programs for medical/social service staff are proliferating. 

Given the potential for errors, health care organizations should not offer or suggest these 

courses as sufficient to communicate with LEP patients/consumers in clinical encounters. It 

can only be misleading to market 8-hour courses in “survival Spanish” to clinicians or health 

care administrators. Still, many medical schools offer or encourage students to take semester 

long (or shorter) courses in “medical Spanish.” 

Family and Friends as Interpreters 

The issue of limiting the role of family and friends as interpreters generated both considerable 

support and dissent from the public comments. This standard in no way contemplates the 

exclusion of family or other companions in the health care encounter; in fact, family and 

others should be present and actively involved in health care delivery, as desired by the 

patient/consumer. But the evidence presented by Downing on interpretation errors when 

untrained individuals are used is too compelling to ignore, and some health care institutions 

have been sued for malpractice related to significant injury and death when family members 

were involved in interpretations. Moreover, family and friends may be able to be more 

involved in patient support and decisionmaking if they do not have the additional burden and 

risk of interpretation. As suggested by the OCR guidance, the best approach with patients who 

have brought their own interpreter is to stress that a trained staff interpreter is being provided 

for their safety and confidentiality, and that if they would still like to use their own 

interpreter, the staff interpreter will remain present to ensure that both the patient and 

clinician are receiving accurate information. As stated in the commentary, minors should 

never be used to interpret, either on behalf of other patients/consumers, or for their parents 

when they are the patient/consumer. An excellent discussion of the potential errors and 

conflicts raised by using children as interpreters can be found online at 

[http://www.nhelp.org/pubs/19990720LEPGuidance.html]. 

76 U.S. Department of Health and Human Services 
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STANDARD 7 

TRANSLATED MATERIALS (MANDATE) 

Standard and Commentary 

7. Health care organizations must make available easily understood patientrelated materials and post signage in the languages of the commonly encountered 

groups and/or groups represented in the service area. 

An effective language assistance program ensures that written materials routinely provided in 

English to applicants, patients/consumers, and the public are available in commonly 

encountered languages other than English. It is important to translate materials that are 

essential to patients/consumers accessing and making educated decisions about health care. 

Examples of relevant patient-related materials include applications, consent forms, and 

medical or treatment instructions; however, health care organizations should consult OCR 

guidance on Title VI for more information on what the Office considers to be “vital” 

documents that are particularly important to ensure translation (65 Fed. Reg. 52762-52774, 

August 30, 2000) at [www.hhs.gov/ocr/lep]. 

Commonly encountered languages are languages that are used by a significant number or 

percentage of the population in the service area. Consult the OCR guidance for guidelines 

regarding the LEP language groups for which translated written materials should be provided. 

Persons in language groups that do not fall within these guidelines should be notified of their 

right to receive oral translation of written materials. 

Signage in commonly encountered languages should provide notices of a variety of patient 

rights, the availability of conflict and grievance resolution processes, and directions to facility 

services. Way-finding signage should identify or label the location of specific services (e.g., 

admissions, pediatrics, emergency room). Written notices about patient/consumer rights to 

receive language assistance services are discussed in Standard 5. 

Materials in commonly encountered languages should be responsive to the cultures as well as 

the levels of literacy of patients/consumers. Organizations should provide notice of the 

availability of oral translation of written materials to LEP individuals who cannot read or who 

speak nonwritten languages. Materials in alternative formats should be developed for these 

individuals as well as for people with sensory, developmental, and/or cognitive impairments. 

The obligation to provide meaningful access is not limited to written translations. Oral 

communication often is a necessary part of the exchange of information, and written materials 

should never be used as substitutes for oral interpreters. A health care organization that limits 

its language services to the provision of written materials may not be allowing LEP persons 

equal access to programs and services available to persons who speak English. 

Organizations should develop policies and procedures to ensure development of quality nonEnglish signage and patient-related materials that are appropriate for their target audiences. At 

a minimum, the translation process should include translation by a trained individual, back 

translation and/or review by target audience groups, and periodic updates. 

It is important to note that in some circumstances verbatim translation may not accurately or 

Office of Minority Health 77 
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appropriately convey the substance of what is contained in materials written in English. 

Additionally, health care organizations should be aware of and comply with existing State or 

local nondiscrimination laws that are not superceded by Federal requirements. 

Discussion 

The Importance of Translated Materials 

Written materials offer an effective way of communicating with large numbers of people, 

supplementing or further explaining information provided by clinicians and other staff, and 

reinforcing key messages that can be forgotten in the plethora of facts and advice that are 

conveyed during a health care encounter. However, the potential benefits of these documents 

are lost if patients/consumers cannot understand the language in which the materials are 

written. Without understandable written materials, patients/consumers have limited access to 

health information and are thus at risk for not following medical directions or health plan 

requirements. A health care organization can help ensure that its LEP patients/consumers 

have equal access to its services by including in its language assistance program translated 

materials that are written in commonly encountered non-English languages and are consistent 

with the culture and literacy levels of target language groups. Providing oral interpretation or 

information in alternative formats is an important step toward mitigating the disadvantages 

faced by LEP individuals who have no written language or are unable to read. 

Materials for Translation 

Two important issues related to the provision of translated materials are what types of 

materials should be translated and for which language groups should translations be provided. 

Both issues are addressed in part by the OCR guidance on Title VI. The guidance provides 

numerous examples of what the Office considers to be “vital” documents warranting 

translation, including applications; consent forms; letters containing important information 

about participation in a program; and notices about the reduction, denial, or termination of 

services or benefits. However, the guidance recognizes that the unique characteristics of each 

federally funded health and social service program are considerations in determining which 

documents and information are considered vital. 

Public comments generated numerous suggestions on the issue of which documents should be 

translated, ranging from “essential or critical documents” to “all needed materials...if it is 

important enough for English-speaking people to have it, everyone should have it.” 

Commenters generally agreed that materials necessary for patients/consumers to access and 

make educated decisions about their health care should be translated. Comments proved a rich 

source of ideas on the types of patient-related written materials that, if translated, would be 

valuable to LEP individuals. Suggestions are highlighted below. 

• Administrative and legal documents—materials requiring informed consent, obligation, or 

acknowledgement of certain legal or financial rights and responsibilities; waivers of rights; 

living wills and advanced directives; emergency room, release, and discharge forms; 

marketing materials; documents establishing and maintaining eligibility for services; 

explanations of benefit coverage packages; evidence of coverage cards and notices of 

noncoverage; information on patient/consumer services and rights; health plan member 

handbooks or critical portions thereof; and appointment slips 

78 U.S. Department of Health and Human Services 
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• Clinical information—prevention and treatment instructions, including how to prevent 

transmission of a contagious disease, what to do before, during, and after a procedure or 

treatment (e.g., surgery, chemotherapy), how to take medications, and how to perform 

routine self-care or self-monitoring 

• Patient education, health prevention and promotion, and outreach materials—brochures, 

fact sheets, pamphlets, promotional flyers and posters, health warnings, immunization 

notices, and other materials that support treatment programs (e.g., for chronic disease or 

reproductive health) and prevention activities (e.g., cancer or high blood pressure 

screenings). 

Languages for Translation 

The OCR guidance calls for translation of written materials in instances when there are a 

significant number or percentage of the population that needs information in a language other 

than English. OCR provides guidelines for determining whether the number or percentage of a 

population is significant. Health care organizations should be familiar with any national, state, 

or local regulations related to the provision of language assistance services and ensure that 

information about these requirements are disseminated to staff members who should know 

about them. This staff includes personnel in member services, member communications, 

health education, outreach, advertising, and public relations as well as direct service providers. 

OCR recognizes that it would be unduly burdensome to require translations in all written 

materials in all of the dozens of different languages that are encountered in certain areas, such 

as large cities. Moreover, several public comments observed that the languages that are most 

commonly encountered shift with population changes over time, particularly among migrant 

populations. However, commenters provided ideas on how organizations can be responsive to 

multiple non-English language groups as well as shifts in commonly encountered languages. 

For example, one county medical center recently implemented a new set of criteria for 

deciding what materials are translated. The hospital used to translate all of its documents to 

the seven most commonly used languages, but its top seven languages kept changing. The 

hospital now matches the types of translated materials to the specific needs of the top language 

groups. For example, because most of the hospital’s Russian population is elderly, it no longer 

automatically translates pregnancy information into Russian. 

Translation Methodologies and Protocols 

In many health care organizations translation of written materials is done on an ad hoc basis 

and without the benefit of guidelines to ensure accuracy and appropriateness for the 

patient/consumer. Organizations may use in-house bilingual individuals who may have no 

background in translation, community-based ethnic organizations that do some translation but 

may lack training or sufficient command of both languages, commercial translation services, 

and translated materials produced by other organizations. However, organizations should 

attempt to use explicit policies and procedures to ensure the quality of translators and the 

translation process. 

Some agencies and organizations have developed protocols for how written materials should 

be translated. For example, the Canadian Multilingual Health Education Net has a Web site 

[http://www.healthtrans.org] that provides guidelines for translating English health education 

materials. A translation task force committee developed such protocols for organizations 

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National Standards for CLAS in Health Car e 

participating in the California Medicaid (Medi-Cal) managed care program. The University of 

Minnesota Translation Laboratory has developed extensive translation protocols for the 

Minnesota Department of Health. Other agencies are developing glossaries and dictionaries in 

a wide variety of languages. The latter resources would facilitate the work of translators and 

help standardize the vocabulary used for medical terms, especially in the languages of more 

recent immigrant populations that may not have Western medical concepts in their native 

languages. 

The development and use of translation tools can help organizations improve the quality of 

translated written materials they make available. Professionally accepted standards currently 

include, at a minimum, translation by a trained individual, back translation and/or review by 

target audience groups, and periodic updates. These minimum standards call for a 

deconstruction approach to translating complicated jargon and concepts that are essentially 

untranslatable or require further explanation. The translation guidelines disseminated by the 

Multilingual Health Education Net emphasize the importance of beginning with an English 

version that is written at a grade 4 to 6 literacy level and using a two-tiered testing system that 

includes review by health care practitioners (for accuracy of medical information) and the 

community (for understandability, cultural context, and accessibility). 

The use of qualified translators is crucial to ensuring the accuracy of translated written 

materials. Organizations should have written criteria for selecting translators and translation 

vendors. At a minimum, organizations should ensure that translators have 1) previous 

experience, education, and training in translation; 2) command of both English and the 

language into which the material will be translated; and 3) familiarity with medical 

terminology. Criteria for selecting translation vendors should include a review of 1) 

translation methods and procedures used, from submission of English copy to printing of 

finished materials; 2) recruitment and training of translators; and 3) procedures for reviewing 

translated materials. Organizations also should have in place knowledgeable people to work 

with translators or vendors during the translation and review process and to determine the 

quality of purchased translations. Public comments emphasized the need to avoid “wildcat” 

translation (e.g. the doctor’s sister who took Spanish in college), however tempting the 

financial advantages. 

Community Involvement 

Ideally, translated written materials should reflect the dialectic and cultural nuances as well as 

the acculturation, educational, and literacy levels of the local target population. Public 

comments emphasized that documents that reflect an awareness of these details demand a 

more sensitive approach than mere literal translation of text. Many experts believe that even 

with translation standards, many documents are better approached through a method of 

developing original written material in the target language that includes collaboration with the 

target community and the writer of the substantive material. For example, focus groups 

discussions with members of the target population can identify any suggestions or instructions 

in the translated material that might be embarrassing or offensive, suggest cultural practices 

that provide more appropriate examples (e.g., eating rice instead of pasta), and check whether 

graphics reflect the diversity of the target community (e.g., facial features, clothing and hair 

styles). This process is especially important for health education and disease prevention 

materials that are intended to motivate behavior change. Because many communities are 

80 U.S. Department of Health and Human Services 
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repeatedly tapped for translation and review services without receiving any reimbursement, 

organizations should consider providing financial compensation or in-kind services. 

Translation of Technical Information 

Many public comments addressed concerns related to translating highly technical medical and 

legal language into consumer-oriented and easily understood language, whether it be English 

or another language. The need to balance medical and legal accuracy with the language, 

culture, and literacy levels of patients/consumers is a complicated issue that involves 

considerable risks for organizations and providers. The difficulties of translating highly 

technical language that is far from consumer-friendly in English are multiple, as the public 

comments indicated. Literal translations can be incomprehensible, irrelevant, or culturally 

insensitive, and poor translations can provide inaccurate information. The challenge of 

addressing the patient’s level of literacy is complicated by the issue of determining and being 

responsive to the person’s level of acculturation and health and legal literacy. 

Some organizations and providers seek legal protection through precise and “watertight” 

wording in informed consent and other standard forms. However, as one person commented, 

in lawsuits, lawyers can target the issue of whether a patient with LEP had true informed 

consent. Several approaches to addressing these difficulties were proposed in the public 

comments. For example, one translator at a hospital meets with doctors or nurses for help 

with the translation of highly technical materials. Another hospital has a separate set of 

criteria for translating forms because they are more specialized than educational materials and 

involve legal issues. One project found it helpful as a first step to get permission to revise and 

simplify the state health department’s standard consent forms in English before undertaking 

translation. Another approach is to produce translated explanatory documents that clarify 

concepts, such as “advanced directives,” that are used on the forms. One language access 

project that encountered difficulties translating concepts into certain languages decided that it 

needed interpreters to explain consent forms and other standardized forms. The danger of this 

approach is that patients/consumers who are not offered interpreters may sign forms without 

understanding the document. 

New Technologies and Alternative Formats 

New technologies offer timesaving alternatives for translation, but not without drawbacks. 

Computers provide a way to store translated documents such as forms and fact sheets that can 

be easily printed and updated, thus allowing organizations to stock less inventory of these 

items. Some organizations may be tempted to use translation software programs to speed the 

process of translating material from English to the target language, but these programs are very 

rudimentary and frequently introduce inaccuracies, particularly when technical language is 

used. Consequently, bilingual staff are required to identify and correct these inaccuracies and 

to add any adaptations for the target community. The Internet offers a useful medium for 

establishing a centralized database/repository of commonly used translated documents and 

glossaries that could be downloaded and customized by anyone with a computer and 

appropriate software. An Internet-based repository would also facilitate ongoing review and 

updates of translated documents—a necessary process to ensure that materials remain current 

with scientific and methodological advances. Multilingual Health Education Net and the 

Multicultural Health Communications Service, Health Department, New South Wales, 

Australia [http://www.mchs.health.nsw.gov/au/] have large collections of online translated 

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health materials in a number of languages. 

Several public comments called attention to the need for alternative formats to address the 

needs of people who cannot read or lack a written language and persons with sensory, 

developmental, and/or cognitive impairments. Community-based organizations have a long 

history of working with people who cannot read and have developed a variety of formats that 

communicate ideas and reinforce important concepts. For example, one center developed a 

video that shows a Haitian woman going through a grocery store and touching indigenous 

food groups that are important for a healthy diet. Radio and audiotapes also are useful for 

people who cannot read. An issue of The Pfizer Journal on health literacy (Giorgianni, 1998) 

gives many examples of how to use pictures to illustrate medical procedures or concepts. 

Photographs or drawings showing the dosage of medications and a clock face with the times to 

take the drugs can help increase adherence to prescription regimens among patients who 

cannot read labels. A photoessay on early cancer detection can explain a screening technique 

with minimal words by showing women going through the steps of getting a mammogram. 

Photo-novellas and comic books rely primarily on pictures to deliver health messages through 

a story format. Storytelling and drama have been used effectively to communicate with people 

who do not have a written language. Large-print, Braille, and audio materials are alternatives 

for people with visual impairments, whereas interpreters who can use American Sign 

Language are needed for persons who are deaf or hard of hearing. 

Need for Oral Interpretation 

Whatever the technology and formats used, translation of written materials should not be 

interpreted as a way to replace oral interpretation. Oral communication is a critical part of the 

exchange of information between a health care organization or provider and 

patients/consumers. Thus, an organization that limits its language services to the provision of 

written materials is, by definition, limiting LEP persons equal access to services. In 

determining how best to provide access to LEP individuals, organizations need to address the 

appropriate mix of written and oral language assistance. 

82 U.S. Department of Health and Human Services 
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STANDARD 8 

ORGANIZATIONAL FRAMEWORK FOR CULTURAL COMPETENCE 

(GUIDELINE) 

Standard and Commentary 

8. Health care organizations should develop, implement, and promote a written 

strategic plan that outlines clear goals, policies, operational plans, and 

management accountability/oversight mechanisms to provide culturally and 

linguistically appropriate services. 

Successful implementation of the CLAS standards depends on an organization’s ability to 

target attention and resources on the needs of culturally diverse populations. The purpose of 

strategic planning is to help the organization define and structure activities, policy 

development, and goal setting relevant to culturally and linguistically appropriate services. It 

also allows the agency to identify, monitor, and evaluate system features that may warrant 

implementing new policies or programs consistent with the overall mission. 

The attainment of cultural competence depends on the willingness of the organization to learn 

and adapt values that are explicitly articulated in its guiding mission. A sound strategic plan 

for CLAS is integrally tied to the organization’s mission, operating principles, and service 

focus. Accountability for CLAS activities must reside at the highest levels of leadership 

including the governing body of the organization. Without the strategic plan, the organization 

may be at a disadvantage to identify and prioritize patient/consumer service need priorities. 

Designated personnel or departments should have authority to implement CLAS-specific 

activities as well as to monitor the responsiveness of the whole organization to the cultural 

and linguistic needs of patients/consumers. 

Consistent with Standard 12, the strategic plan should be developed with the participation of 

consumers, community, and staff who can convey the needs and concerns of all communities 

and all parts of the organization affected by the strategy. And, consistent with Standards 9, 10, 

and 11, the results of data gathering and self-assessment processes should inform the 

development and refinement of goals, plans, and policies. 

Office of Minority Health 83 
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Discussion 

Policy Basis for a CLAS Organizational Strategy 

The need for a strategic and structured organizational approach to cultural competence was 

prominent in both the original source policy documents and the public comments. In the 

original analysis of policy documents used to develop the CLAS standards, many of these 

documents outlined the need for an organizational planning approach to implementing 

cultural and linguistic competence activities. Contract language used in California’s Medicaid 

(Medi-Cal) managed care program contains the most extensive requirements for organizational 

process in the provision of culturally and linguistically appropriate services, including the 

development of a cultural and linguistic services plan, with activities, time lines, and 

milestones; identification of responsible individuals (including organizational charts, types and 

responsibilities of staff); the development and implementation of standards and performance 

requirements; performance monitoring; and protocols for appointment scheduling and system 

coordination. 

The Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) is 

similarly explicit about the need for policies and procedures on language assistance services, 

listing implementation of these components as one of the four key activities that will facilitate 

compliance with the Title VI. The Maine Medical Center compliance agreement, available 

online [http://www.hhs.gov/ocr/mmc07172000.html], outlines a model organizational 

structure and policies for achieving compliance with the OCR guidance. These two documents 

reflect OCR’s recognition of the difficulties involved in delivering linguistic services to a 

diverse patient population according to the Federal standards of timeliness and 

appropriateness without a formal structure for organizing and accessing these services. For 

example, having qualified interpreters and translated materials available at the time of need is 

nearly impossible without designated staff who are responsible for organizing and dispatching 

the services. 

A similar argument can be made for overall organizational cultural competence. The American 

Nurses Association noted in their written comments that without a formal structure in place, 

it is very difficult to provide culturally competent, linguistically appropriate services. 

“Frequently, a nurse may be placed in a compromised situation due to the lack of a clear 

commitment by the health care organization to provide her/him with adequate resources or 

support necessary to provide culturally competent, linguistically appropriate services. A 

standard which identifies the health organization’s policies and procedures regarding CLAS 

would go a long way to assure that all health care providers would be informed of the 

expectation and support for the provision of these services.” CLAS services would include 

both obvious and subtle indicators of a culturally competent environment: the inclusion of 

culturally appropriate magazines and health education materials in the waiting and treatment 

rooms, appropriate food choices in a hospital, the use of culturally appropriate artwork and 

posters, cultural competence training for all staff, as well as the other activities outlined in all 

the CLAS standards. The detail offered by the public comments reveals a rich breadth of 

wisdom and experience in the implementation of cultural competence activities, and this input 

is reflected in the discussion below. 

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Integration of CLAS throughout an Organization 

Many comments described the delicate balancing act between the seamless integration of 

CLAS into the mission and activities of the organization, and the need for prominent goals 

and policies to focus attention on what may be new or undervalued activities. According to 

one comment, “Cultural competence should not be something ‘over there.’ The services, 

strategic goals, plans, policies, and staff designations should not be framed in a way that a 

department, initiative, or activities are set apart from the rest of the life of the organization. 

Cultural competency needs to be practiced in a way that is fully integrated into the life of an 

organization.” Another comment noted, “It is extremely important that a culturally competent 

organization have a philosophical and ethical basis, not just policies, rules, or strategies to 

address culturally and linguistically appropriate services. Cultural competency needs to be 

grounded in the organization’s identity—how it recruits and staffs employees, how it treats 

customers, how it conducts business. Cultural competency needs to flow both from the top 

down and from the bottom up.” Incorporating CLAS activities and values into the 

organization’s mission statement and comprehensive management strategy was frequently 

mentioned as a critical first step. 

Accountability from the Top and throughout the Organization 

Nearly half of the public comments on this standard addressed the issue of internal and 

external accountability for cultural competence in an organization. Some comments identified 

a bottom-up or front- line staff approach to initiating cultural competence activities. However, 

most comments recognized the need for top management support for cultural competence to 

assure accountability and longevity, as well as shared responsibility for implementation 

throughout the organization. Several comments suggested true accountability and authority 

for change lies at the governance level. One comment observed that a “comprehensive 

management strategy must come from the top of the hierarchy of the health care organization, 

which for most large organizations is the board of trustees. For example, at the Mount Sinai 

Hospital and Mount Sinai School of Medicine, the Board of Trustees has the capacity to effect 

change in the entire institution and impact all levels of staff more effectively than individual 

department chairs.” However, another comment noted that these leaders are not always ready 

to act on CLAS, and change can be initiated by others. “From our experience, we are seeing 

[the change come] from the providers. The providers are getting very frustrated with not 

being able to speak the [patient’s] language, of not being able to give clear guidance, of 

spending money on people who are coming back all of the time. So [the providers] are the 

ones that are starting their own... cultural competence teams.” Frequently, these staff-driven 

teams develop so much expertise and authority among their peers that they are invited by 

administrators to offer guidance on how to make changes across the organization. 

Motivation for change is a first step; but accountability for implementing and sustaining the 

change is equally important. In general, it was observed that managers should not be any more 

responsible for change than other staff. As one comment stated, “Cultural competency policy 

needs to be followed consistently throughout the organization. Each person at every level of 

the organization needs to understand the philosophy and required practice.” But the need for 

designated staff who monitor the development and execution of policies and procedures is 

essential. This may involve creating an office of diversity, or charging a senior manger with 

cultural competence as part of his/her portfolio, or creating a team that works across an 

organization. One model described a cultural competency committee that worked with existing 

Office of Minority Health 85 
National Standards for CLAS in Health Car e 

departments. “The cultural competency committee did not do training; it worked with the 

training department on curriculum, infusion, and identifying speakers. Committee members 

met with supervisors about issues and problem solving, and then the supervisors would 

develop standards and tools. The committee was the impetus for the organization [to conduct 

CLAS activities] but not the doers. Committee members had accountability to senior 

management for their work, but lines of accountability within the organization stayed the 

same. The cultural competency “add-ons” became part of the ongoing chain of command and 

responsibility.” 

Implementation of CLAS Activities 

The strength and the challenge of the CLAS standards is that they attempt to be 

comprehensive in describing all the activities that an organization might undertake to be 

culturally competent. For an organization with little or no experience in delivering culturally 

and linguistically appropriate health services, the prospect of taking action on 14 different 

types of activities is understandably daunting. Many commentators observed the tension 

between specificity in the standards and the need for flexibility in implementation. “[The 

standards need] to be prescriptive but also incremental.... if it is too overwhelming, people 

don’t want to do anything.” Another comment suggested that “striving for cultural 

competence within an organization is a developmental process and occurs over an extended 

period of time. Health care organizations should be encouraged to develop a comprehensive 

plan to incorporate values, structures, policies, practices, and procedures at all levels within 

the system. The plan needs to include incremental and measurable short-term and long-term 

outcomes.” Various comments called for a phased-in implementation process, step-by-step 

guidelines, and checklists. These tools could be developed by individual healthcare 

organizations or by the HHS Office of Minority Health as a follow-up to the CLAS standards 

development process. An Illinois organization, the Heartland Alliance, has developed one 

such guide, Building Linguistic and Cultural Competency: a Toolkit for Managed Care 

Organizations and Provider Networks that Service the Foreign-Born (1998). Although this 

manual does not track the CLAS standards explicitly, it includes many of the most important 

CLAS elements as well as resources for implementation. Whatever tool or guide is used, 

health care organizations could decide to focus their preliminary efforts on implementing one 

or two of the standards. Alternatively, organizations could determine a logical, standard-bystandard implementation process in which each step would build on the previous one. One 

potential implementation sequence could work as follows (the relevant CLAS standard 

number is in parenthesis): 

Laying the groundwork: 

• Internal assessment (9) 

• Community profile (11) 

• Community engagement (12) 

Organizational supports: 

• Plans and accountability structure (8) 

• Data collection systems (10) 

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Services: 

• Language assistance (4,5,6,7) 

• Staff diversity and cultural competence training (2,3) 

• Culturally sensitive care and environment (1) 

Monitoring: 

• Ongoing assessment: organization and staff (3, 9) 

• Outcomes research and evaluation (9) 

The complexity raised by a multi-stage implementation process obviously reinforces the need 

for Standard 8. It would be impossible to implement and manage new CLAS activities without 

a structured and strategic approach. 

Involvement of Communities and Patient/Consumers 

This standard’s commentary mentions the importance of involving communities and 

patients/consumers in the development of an organization’s management strategy on cultural 

competence, and this issue is more fully explored in Standard 12. In the context of Standard 8, 

it is useful not to overstate or understate the role of community in developing and executing 

the organizational framework for CLAS. With the exception of mandated consumer 

representation on the boards of directors of federally funded community health centers, few 

organizations have structures in place to involve community representatives (or even staff) at 

every stage of planning and implementation. But many health care organizations maintain 

very close ties and sponsor regular meetings with consumers and community leaders to test 

ideas and solicit feedback on services. The effort may seem considerable, but if services are illconceived or do not meet the true needs of the community, the authenticity of the health care 

organizations’ commitment to cultural responsiveness will be questioned. The New York 

University New York Downtown Hospital has found that regular consultation with the 

Chinese community in their service area has resulted in health care services that community 

leaders support and local consumers use. Together, these leaders and consumers constitute an 

enthusiastic, informal referral system that brings Chinese patients/consumers from several 

surrounding States. Hospital leadership has recognized that developing close relationships 

with the community over many years has been instrumental in bringing the institution from 

the brink of closure to financial stability. 

Office of Minority Health 87 
National Standards for CLAS in Health Car e 

STANDARD 9 

ORGANIZATIONAL SELF-ASSESSMENT (GUIDELINE AND 

RECOMMENDATION) 

Standard and Commentary 

9. Health care organizations should conduct initial and ongoing organizational 

self-assessments of CLAS-related activities and are encouraged to integrate 

cultural and linguistic competence-related measures into their internal audits, 

performance improvement programs, patient satisfaction assessments, and 

outcomes-based evaluations. 

Ideally, these self-assessments should address all the activities called for in the 14 CLAS 

standards. Initial self-assessment, including an inventory of organizational policies, practices, 

and procedures, is a prerequisite to developing and implementing the strategic plan called for 

in Standard 8. Ongoing self-assessment is necessary to determine the degree to which the 

organization has made progress in implementing all CLAS standards. The purpose of ongoing 

organizational self-assessment is to obtain baseline and updated information that can be used 

to define service needs, identify opportunities for improvement, develop action plans, and 

design programs and activities. The self-assessment should focus on the capacities, strengths, 

and weaknesses of the organization in meeting the CLAS standards. 

Integrating cultural and linguistic competence-related measures into existing quality 

improvement activities will also help institutionalize a focus on CLAS within the organization. 

Linking CLAS-related measures with routine quality and outcome efforts may help build the 

evidence base regarding the impact of CLAS interventions on access, patient satisfaction, 

quality, and clinical outcomes. 

Patient/consumer and community surveys and other methods of obtaining input are important 

components of organizational quality improvement activities. But they should not constitute 

the only method of assessing quality with respect to CLAS. When used, such surveys should 

be culturally and linguistically appropriate. 

Discussion 

The Role of Organizational Self-Assessment 

Ongoing organizational self-assessment is a process often used to examine factors that might 

be impeding a service delivery system’s effectiveness and performance. It is essential for 

planning, implementing and evaluating the quality of any kind of service, including CLAS. 

Cultural audits are a specific form of organizational assessment that focus on identifying 

problems and developing strategies relevant and specific to developing CLAS. In the area of 

cultural and linguistic competence, many organizations remain largely unaware of structural 

and behavioral factors that create barriers to providing quality service for diverse populations. 

Although some health care organizations may attempt to provide CLAS through targeted 

programs, they seldom link these efforts with other organizational activities that focus on 

policy and decision-making related to outcomes accountability. The development of overall 

organizational cultural and linguistic competence will take both time and a better 

88 U.S. Department of Health and Human Services 
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understanding of the potential impact of CLAS on outcomes and satisfaction. However, there 

are steps organizations can take to assess their progress on the journey. 

As a first step, organizations should conduct a cultural audit using existing cultural 

competence assessment tools to inventory structural policies, procedures, and practices. These 

tools provide general guidance to determine whether the core structure (e.g., management, 

governance, delivery systems, and customer relation functions) necessary for providing CLAS 

is in place. Results from this internal audit should then be used to identify assets (e.g., 

bilingual staff members who could be used as interpreters, existing relationships with 

community-based ethnic organizations) and weaknesses (e.g., no translated signage or cultural 

competence training), as well as opportunities to improve the structural framework (e.g., 

revise the mission statement or recruit people from diverse cultures into policy and 

management positions). Only after such a self-assessment can organizations prepare adequate 

strategic plans for developing CLAS (see Standard 8). Subsequent ongoing self-assessment 

helps organizations chart their progress in implementing the CLAS standards and refine their 

strategic plans. 

Tools for Organizational Self-Assessment of Cultural Competence 

Organizational self-assessment of cultural competence faces some of the same limitations as 

assessing the cultural competence of individuals. Although many tools for organizational selfassessment have been developed and cataloged, no one assessment instrument or process has 

been specifically validated against another. Moreover, some are suited to a particular type of 

institution (e.g., hospital, managed care organization), and none are based on the CLAS 

standards. Nevertheless, useful compilations of tools do exist. The Judge Baker Children’s 

Center uses an analysis of organizational self-assessment tools as the foundation for an 

extensive manual describing how children’s mental health providers can conduct and 

implement a culturally competent assessment process. 

Other assessment tools/processes have been designed and field tested. The National Center for 

Cultural Competence developed a process that has been conducted with organizations in 

several states. Another process developed by the National Public Health and Hospital Institute 

was tested in hospitals and redesigned as an organizational self-assessment tool. Dr. Miguel 

Tirado at California State University Monterey Bay developed a cultural competence 

assessment tool for managed care organizations based on his previous assessment tool for 

individual health professionals (Tirado, 1996). The State of Massachusetts currently uses a 

tool to assess and rate the cultural competence of hospitals. This tool will eventually be 

modified for use with managed care organizations participating in Medicaid. Polaris Research 

in San Francisco has an assessment process for organizations that provide HIV services, and 

the Heartland Alliance of Illinois offers a cultural competence toolkit for managed care 

organizations that includes a blueprint of organizational competencies, assessment criteria, 

and best practices. Although several of these products and processes have built upon the 

approaches developed by previously published tools, each reflects the specific definitions, 

goals, and objectives of its developers rather than any universally accepted set of criteria. 

CLAS-Related Measures in Performance Improvement and Outcomes Assessments 

Integrating measures related to cultural and linguistic competence into existing quality 

improvement programs could help organizations learn whether CLAS delivery processes 

produce the desired results. Although organizational self-assessment (the first part of this 

Office of Minority Health 89 
National Standards for CLAS in Health Car e 

standard) is presented as a guideline, the current evidence base supports only the 

recommendation that organizations integrate CLAS-related measures into exiting quality 

improvement activities (the second part of the standard). No consensus on state-of-the-art 

measures of quality, satisfaction, and outcomes related to CLAS currently exists. However, 

public comments suggest that there are many opportunities for organizations to collect basic 

data about ethnic clients and CLAS utilization, and to systematically examine the quality of 

these services as well as their impact on performance and outcomes. For example, the draft 

specifications by the Health Resources and Services Administration (HRSA) for Medicaid 

managed care contracts suggest that organizations could conduct focused studies that explore 

1) accessibility of interpreter services; 2) the effectiveness of cultural competence training for 

providers and non-clinical staff; 3) differences in the use of services among different racial and 

ethnic minority groups; and 4) the impact of culturally competent service provision on the 

health outcomes, health status, and satisfaction of enrollees. 

Another suggested approach was to include in performance improvement programs one or 

more evaluation questions that focus on whether there are differences among ethnic or 

language groups in service utilization (e.g., not appearing for appointments, termination of 

enrollments). Such data are useful in refining programs because they identify potential 

problems that are highly actionable. For example, an assessment of “no-show” data could 

reveal certain times of day at which patients/consumers from a particular group are more 

likely to break their appointments. Determining why these times are less convenient and 

adjusting appointment times for these individuals could increase access to services among the 

group. 

The Center for Healthy Families and Cultural Diversity, University of Medicine and Dentistry 

of New Jersey-Robert Wood Johnson Medical School, has developed a Participatory Quality 

Improvement (PQI) model for systematically linking clinical quality improvement with 

measures of organizational, provider, and community/patient cultural competence. Now being 

tested, PQI offers a promising way for organizations to measure quality improvement in 

dimensions related to the elimination of racial and ethnic health disparities. 

One relatively easy way to integrate cultural competence-related measures into performance 

improvement activities is to add a question about self-identified ethnicity to an organization’s 

existing patient surveys. These data can be segregated by ethnicity to compare 

patient/consumer satisfaction among ethnic groups and to identify any specific service-related 

differences. However, the data collection instrument must be culturally and linguistically 

appropriate, with translated questionnaires or bilingual interviewers for telephone surveys. 

Harvard Pilgrim Health Care, a managed care organization in Massachusetts, developed a 

patient cultural audit that is being pilot tested at three multi-specialty sites. Preliminary results 

indicate that the survey, which is available in seven languages, provides information that helps 

sites focus on what patients want, what is working well, and what needs additional attention. 

It should be noted that although patient/consumer satisfaction surveys are one of the most 

frequently used methods of evaluating services, they might not yield a true picture of the 

quality of services. Research shows that it is particularly difficult to design patient satisfaction 

surveys to capture the patient’s complete view of quality and satisfaction. For example, neither 

patients nor physicians may truly be able to assess the quality of the language assistance 

services because neither has the linguistic capacity to verify the competency or accuracy of the 

90 U.S. Department of Health and Human Services 
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interpreter or translation. Additionally, cultural variations abound in how clients respond to 

satisfaction-related questions, especially when feedback might be negative. 

Health care organizations that integrate queries related to race, ethnicity, and language into 

utilization or risk management systems may find trends that could be related to these factors 

or be affected by the presence or absence of cultural and linguistic services. For example, an 

analysis of patient records at two Midwestern hospitals preparing for a merger found that 

patients with certain conditions had shorter lengths of stay and lower rates of return for the 

same condition at one hospital. Although the sample was small, further analysis offered a 

statistically significant indication that the hospital’s use of interpreters played a role in the 

better outcomes. 

Assessing the effectiveness of CLAS in terms of health outcomes requires aggregate data on 

patient/consumer race and ethnicity. Until organizations implement Standard 10, which calls 

for the collection of such data, many may attempt data aggregation by ethnicity on the basis of 

last names. This approach is flawed by overlaps that occur between subpopulations (e.g., 

Cuban and Mexican Americans), the fact that immigrants often change the spelling of their 

last name, and the possibility that changes as a result of marriage may reduce the accuracy of 

last names as markers of ethnicity. Instituting collection of race, ethnicity, and language data is 

necessary to ensure appropriate monitoring of patient/consumer service needs and utilization, 

quality of care, and outcome patterns. 

Office of Minority Health 91 
National Standards for CLAS in Health Car e 

STANDARD 10 

COLLECTION OF DATA ON INDIVIDUAL PATIENTS/CONSUMERS 

(GUIDELINE) 

Standard and Commentary 

10. Health care organizations should ensure that data on the individual 

patient’s/consumer’s race, ethnicity, and spoken and written language are collected 

in health records, integrated into the organization’s management information 

systems, and periodically updated. 

The purposes of collecting information on race, ethnicity, and language are to: 

• Adequately identify population groups within a service area; 

• ensure appropriate monitoring of patient/consumer needs, utilization, quality of care, and 

outcome patterns; 

• prioritize allocation of organizational resources; 

• improve service planning to enhance access and coordination of care; and 

• assure that health care services are provided equitably. 

Collection of data on self-identified race/ethnicity should adhere to the standard procedures 

and racial and ethnic categories specified in the Office of Management and Budget’s most 

current policy directive and adapted in the U.S. Census 2000. To improve the accuracy and 

reliability of race and ethnic identifier data, health care organizations should adapt intake and 

registration procedures to facilitate patient/consumer self-identification and avoid use of 

observational/visual assessment methods whenever possible. Individuals should be allowed to 

indicate all racial and ethnic categories that apply. Health care organizations can enhance their 

information on subpopulation differences by collecting additional identifiers such as selfidentified country of origin, which provides information relevant to patient/consumer care 

that is unobtainable from other identifiers. 

The purpose of collecting information on language is to enable staff to identify the preferred 

mode of spoken and written communication that a patient/consumer is most comfortable 

using in a health care encounter. Language data also can help organizations develop language 

services that facilitate LEP patients/consumers receiving care in a timely manner. To improve 

the accuracy and reliability of language data, health care organizations should adapt 

procedures to document patient/consumer preferred spoken and written language. Written 

language refers to the patient/consumer preference for receiving health-related materials. Data 

collected on language should include dialects and American Sign Language. 

For health encounters that involve or require the presence of a legal parent or guardian who 

does not speak English (e.g., when the patient/consumer is a minor or severely disabled), the 

management information system record and chart should document the language not only of 

the patient/consumer but also of the accompanying adult(s). 

Health care organizations should collect data from patients/consumers at the first point of


contact using personnel who are trained to be culturally competent in the data collection


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process. Health care organizations should inform patients/consumers about the purposes (as 

stated above) of collecting data on race, ethnicity, and language, and should emphasize that 

such data are confidential and will not be used for discriminatory purposes. No 

patient/consumer should be required to provide race, ethnicity, or language information, nor 

be denied care or services if he or she chooses not to provide such information. All 

patient/consumer data should be maintained according to the highest standards of ethics, 

confidentiality, and privacy, and should not be used for discriminatory purposes. 

Discussion 

Legality and Purposes of Collecting Data on Race, Ethnicity, and Language 

Public comments on Standard 10 indicate that confusion remains as to whether the collection 

of data on race and ethnicity is permissible by law. Since 1997, the U.S. Department of Health 

and Human Services (HHS) has required the inclusion of information on race and ethnicity in 

HHS data collection systems (HHS, 1997). In recent correspondence with a national health 

care organization, the Office of Civil Rights (OCR) affirmed the legality and importance of 

collecting and analyzing these data to improve services. OCR considers collecting racial and 

ethnic data a critical part of any comprehensive strategy to eliminate health disparities. The 

Office strongly encourages collecting such data to help organizations focus care on health 

conditions prevalent in specific demographic groups and provide CLAS to its 

patients/consumers. Through analyses of race and ethnicity data, health care organizations 

can identify and track similarities and differences in plan performance and quality of care in 

ethnic, cultural, and geographic communities. OCR often requests race/ethnicity data on 

clients to assess whether programs receiving Federal funds are in compliance with Title VI 

(OCR, 2000). Massachusetts, California, and Arizona are among the States that collect race 

and ethnicity data in their Medicaid and State Children’s Health Insurance Programs. 

In addition to the purposes OCR cites for collecting race and ethnicity data, public comments 

suggested other compelling reasons. For example, clinicians can use these data to make more 

accurate assessments, diagnoses, and treatment evaluations and interventions, based on 

research findings about specific physical, biologic, and physiological variations (e.g., in disease 

and drug metabolism) found among different racial and ethnic groups. One commenter noted 

that race and ethnicity data could be used to identify and understand general patterns and 

trends in accessing care as well as cross-cultural differences in outcomes. However, needs 

assessments (as called for in Standard 11) are necessary to capture the details of a 

community’s resources, assets, and needs. 

Standardization of Data 

Numerous public comments emphasized the need to standardize race/ethnicity data, noting 

that one of the difficulties in analyzing these data is the wide variation of classification and 

collection methodologies. Standardizing racial and ethnic categories was suggested as an 

important way to facilitate research and analysis. Collaborative efforts among local, state, and 

Federal agencies to collect the same type of information were recommended to foster the 

sharing and broader use of data. Yet it was also considered vital that the categories allow for a 

greater variety of self-identified ethnicity. The OMB guidance on the classification of Federal 

data on race and ethnicity provides an existing standard that is followed by all Federal 

agencies. The standard has five minimum categories for data on race (American Indian or 

Office of Minority Health 93 
National Standards for CLAS in Health Car e 

Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, 

and White) and two categories for data on ethnicity (Hispanic or Latino and Not Hispanic or 

Latino). However, these categories were expanded for U.S. Census 2000 to include four 

Spanish/Hispanic/Latino, seven Asian, and four Pacific Islander categories. Census 2000 also 

allows for respondents to self-identify one or more races. Although organizations are urged to 

use this classification system as a base for data collection, gathering more detailed information 

on subpopulations, with linkages to these categories, also is encouraged 

Additional Identifiers 

In addition to standardized racial and ethnic categories, HHS encourages the collection of data 

on other variables, such as cultural background and socioeconomic status, that may be useful 

in assessing and improving health care (HHS, 1997). Public comments also suggested that 

health care organizations collect data on country of origin as a way to identify characteristics 

of subpopulations not necessarily revealed by self-identified race/ethnicity or preferred 

language. For example, the needs of a Somali refugee population are very different from those 

of third-generation African Americans. Similarly, one commenter reported that there are 36 

different Asian communities in a San Francisco service area. Information on country of origin 

also can identify patients/consumers who may be at higher risk for illnesses such as hepatitis 

or tuberculosis, based on the results by international studies conducted by the Centers for 

Disease Control and Prevention. Acculturation data also might be important. For example, 

pregnancy outcomes might vary considerably between the first and second generation of 

immigrants from West Africa. 

Commenters suggested that data on language be inclusive of diverse dialects and languages 

such as ASL. Because some languages have many distinct dialects (e.g., Cantonese and 

Mandarin Chinese), collecting specific data on the dialect of the patient’s/consumer’s spoken 

language is critical to ensuring linguistically appropriate care. Including a code for signing 

systems such as ASL will facilitate the availability of appropriate language services for deaf or 

hard-of-hearing individuals. It may also be important to distinguish between written and 

spoken communication because it cannot be assumed that individuals’ primary written 

language are the same as their primary spoken language. For example, an LEP client may 

speak English well enough not to need an interpreter. However, that client may not be able to 

read English, and therefore would like to receive his or her correspondence in another 

language. A different individual may be fluent in speaking Cantonese Chinese but may not be 

able to understand written Chinese. Collecting data on both written and spoken 

communication preferences can help health care organizations provide appropriate 

interpretation and translation services. 

Confidentiality Issues 

Many diverse cultural groups may be afraid of negative reprisals for providing personal 

information such as race, ethnicity, and language. Undocumented populations may be 

unwilling to volunteer this information for fear that they will be reported to the U.S. 

Immigration and Naturalization Service. Other patients may believe that they will receive 

disparate medical services as a result of answering questions about race, ethnicity, or language 

in a medical encounter. Still others may worry about being asked to pay higher insurance 

premiums based on race or ethnicity. Public comments also indicate that some providers are 

concerned about collecting data from their patients because they have no way to ensure that 

the data will not be misused later. 

94 U.S. Department of Health and Human Services 
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Public comments emphasized the obligation of organizations to ensure that all 

patient/consumer data are maintained according to the highest standards of ethics, 

confidentiality, and privacy. Information on race, ethnicity, and language should never be used 

for discriminatory or profit-making purposes, and should never be required of 

patients/consumers who do not wish to provide it. Data collection should never compromise 

the relationship between patient and provider, and the client should never be put at risk to 

collect data. Just as important is the organization’s obligation to inform patients/consumers, 

and, ideally, the community, about the purpose of collecting such data. Patients/consumers 

and the community need to be assured that the information is being gathered for their benefit. 

Health care organizations should follow the new Federal regulation concerning the privacy of 

patients’ health information, if allowed to stand. The final rule, which is provided for under 

the Health Insurance Portability and Accountability Act of 1996, requires health care plans 

and providers to obtain their patients’ consent for both routine and nonroutine use and 

disclosure of health records. The regulation also calls for plans and providers to give patients a 

clear written explanation of how their health information can be used, kept, and disclosed. 

(HHS, 2000) 

Public comments provided practical suggestions for helping to ensure the confidentiality of 

individual data in management information systems (MIS). For example, systems could use 

codes for data such as race/ethnicity that would never be linked to patients’/consumers’ 

names but used only in aggregate to track outcomes. Another comment suggested that 

organizations could design MIS that allow access to race/ethnicity data only to certain 

approved personnel. To determine which staff members are given access, it is important for 

organizations to clarify the purpose of the data and who needs to use them. Organizations 

should ensure that all staff members using MIS information regularly receive training on 

client record confidentiality. One commenter suggested that organizations should consider a 

system of consent and collaboration in which patients/consumers consent to have their needs 

(e.g., for language services) communicated, and those needs are respected throughout the 

various systems through which the patients/consumers travel. 

Management Information Systems 

Collecting data on race, ethnicity, and language is not yet a universal practice, and fields for 

such data are not part of every health care organization’s existing MIS. However, one 

commenter noted that many managed care organizations and hospitals are in a phase of 

changing and upgrading their information technology systems, thus offering a window of 

opportunity for building databases that can collect information on race, ethnicity, and 

language. For example, health care organizations designing or upgrading their MIS could learn 

from Harvard Pilgrim Health Care and other organizations, which have found that they need 

to allow for coding of more than a dozen different languages. 

The State of Washington’s Department of Social and Health Services has an Automated Client 

Eligibility System (ACES) that goes even further in tracking the language of its clients. ACES 

currently has a primary language field that accepts 88 different language codes (listed on a 

help screen), including one for Sign Language. There is also code for “Other Language,” the 

name of which can be typed on a narrative screen. ACES can also generate correspondence in 

8 supported languages, whose basic text for all ACES letters is contained in the system; 

correspondence in the other languages is printed in English and sent to a contractor for 

Office of Minority Health 95 
National Standards for CLAS in Health Car e 

translation. Modification of ACES is underway to include two primary language fields—one 

for written communication and one for spoken communication. Each field will have its own 

help screen listing of valid codes. Staff will be required to provide a valid primary language 

code for each field. For example, one client may have Chinese as the primary written 

communication and Chiu Chow, a Chinese spoken dialect, as the spoken communication. 

Public comments suggested that taking advantage of Web-based enrollment forms can make it 

easier to update and adjust data collection fields. Organizations also can consider building 

crosswalks between their main databases, which are usually written in difficult computer 

languages, and parallel systems with more user-friendly software (e.g., Microsoft Access) that 

allow easier access to data on race, ethnicity, and language. Kaiser Permanente of Northern 

California collects five data points related to language: primary and secondary spoken 

language, primary and secondary written language, and the need for an interpreter. 

Information to update these five language fields is collected during routine queries about the 

member’s most current address and phone number (e.g., during calls to make appointments or 

check-ins with receptionists). 

It is recognized that not all health care organizations have the advantages of Harvard Pilgrim 

Health Care and Kaiser Permanente, which have more control over their service delivery 

systems and providers than do most other plans. For many health care organizations, 

especially small practices, the addition of data fields to collect race/ethnicity and language data 

may create a considerable burden. One way to phase in the fulfillment of this standard would 

be to incorporate fields for the additional data in any future upgrades to an organization’s 

MIS. States could help by requiring the collection of data on race, ethnicity, and language on 

their enrollment forms for Medicaid and the State Children’s Health Insurance Program and 

sharing this information with health care organizations or plans to which enrollees are 

assigned. However, a State’s failure to collect and share race, ethnicity, and language data does 

not absolve organizations and plans of the responsibility to do so. It is ultimately the 

organizations and plans that benefit from, and bear responsibility for, collecting the data. All 

organizations should capture race, ethnicity, and language information at least in the patient’s 

chart and make it available to staff who schedule appointments. This minimal compliance is 

necessary to ensure that patients receive CLAS. 

Data Collection at First Point of Contact 

Public comments raised the important issue of the potential for variations in race, ethnicity, 

and language data, depending on when such data are collected (e.g. time of enrollment vs. time 

of service). There also may be multiple points of entry into a health care organization, and 

information collected at one point may not be routinely shared across other service 

components. Ideally, for programs requiring enrollment (i.e. managed care programs), the 

entity responsible for enrollment could collect these data at the time of enrollment, and then 

pass the information to the provider. In other cases, providers such as physicians or 

pharmacists could collect and record this information at the first point of contact. The 

information should be recorded not only in the patient record but also communicated to other 

departments that might have contact with the patient, such as billing or member services. One 

hospital in Seattle that uses a computer system for patient information and appointment 

scheduling has a non-optional field for querying the patient about primary language at the 

initial intake, and forwards this information automatically to the appropriate clinical 

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department and the interpreter services department for each appointment. An interpreter is 

automatically scheduled unless a subsequent evaluation reveals that such language services are 

not needed. 

Some health plans that now collect data on race, ethnicity, and language from new members 

have devised plans to obtain this information from existing members. For example, Kaiser 

Permanente of Northern California began instructing personnel to collect missing language 

data from existing members when they called for appointments. A mandatory field ensures 

that language data is collected before the record is completed, and a script helps staff explain 

why members are being asked for this information. Contests across hospitals have resulted in 

some sites already gathering language data on 70 percent of their membership. 

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STANDARD 11 

COLLECTION OF DATA ON COMMUNITIES (GUIDELINE) 

Standard and Commentary 

11. Health care organizations should maintain a current demographic, cultural, 

and epidemiological profile of the community as well as a needs assessment to 

accurately plan for and implement services that respond to the cultural and 

linguistic characteristics of the service area. 

The purpose of this standard is to ensure that health care organizations obtain a variety of 

baseline data and update the data regularly to better understand their communities, and to 

accurately plan for and implement services that respond to the cultural and linguistic 

characteristics of the service area. 

Health care organizations should regularly use a variety of methods and information sources 

to maintain data on racial and ethnic groups in the service area. It is important that health 

care organizations go beyond their own data, such as marketing, enrollment, and termination 

figures, which may provide an incomplete portrait of the potential patient/consumer 

population, many of whom may not be aware of or use the organization’s services. A more 

useful and in-depth approach would use data sources such as census figures and/or 

adjustments, voter registration data, school enrollment profiles, county and State health status 

reports, and data from community agencies and organizations. Both quantitative and 

qualitative methods should be used to determine cultural factors related to patient/consumer 

needs, attitudes, behaviors, health practices, and concerns about using health care services as 

well as the surrounding community’s resources, assets, and needs related to CLAS. Methods 

could include epidemiological and ethnographic profiles as well as focus groups, interviews, 

and surveys conducted in the appropriate languages spoken by the patient/consumer 

population. Health care organizations should not use the collected data for discriminatory 

purposes. 

In accordance with Standard 12, health care organizations should involve the community in 

the design and implementation of the community profile and needs assessment. 

Discussion 

The Importance of Collecting Data on Communities 

Social ecological theories suggest that health status is influenced not only by individual 

attributes such as genetics and health behaviors but also by the physical, social, and cultural, 

dimensions of a person’s environment (Stokols, 1996). Consequently, health care 

organizations need to understand their communities as well as their patient/consumer 

populations to provide quality health care services. This standard focuses on two tools for 

helping organizations understand their communities—a demographic, cultural, and 

epidemiological profile of the community and a needs assessment. These tools can help 

providers and policymakers develop appropriate services and evaluate access to, and utilization 

of, those services. 

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Many people in a service area, especially individuals with limited English proficiency (LEP), 

may be unaware of an organization’s services and never enroll in its programs. Consequently, 

it is important to collect data about potential as well as current patient populations and to use 

as many data sources as possible, including sources outside the organization itself. Because 

many characteristics of a community change over time, it is also critical that health care 

organizations ensure that data on their community is up to date. Although routine updates of 

community information should take place periodically, some organizations might consider an 

annual update too burdensome. To address this issue without being too prescriptive, the 

standard calls for organizations to maintain a current profile and needs assessment, and the 

commentary calls for organizations to obtain baseline data and update it regularly. 

Types of Relevant Data 

Health care organizations need to learn as much as possible about their communities using 

both qualitative and quantitative methods. This standard allows organizations flexibility in 

determining the types of data they collect. Relevant types of data have been suggested by the 

document review conducted for the CLAS standards project, draft Health Resources and 

Services Administration (HRSA) Medicaid contract language, and public comments. For 

example, data collection required by some source documents includes descriptions of 

geographic, demographic, and socioeconomic status; languages spoken in the community; 

population densities; ecological factors; and cultural needs. Other requirements in various 

source documents include an analysis of the cultural needs and health practices and behaviors 

of ethnic groups and the development of a database on ethnic/cultural needs of patients. 

Source documents also address documentation of requests for culture-specific services, data 

development of utilization trends and services in preferred languages, and documentation that 

all hospital data are analyzed by race and ethnicity. 

Some source documents also require organizations to assess various factors related to the need 

for language access services. The types of data and analysis called for in this area include a 

report on the size and demographics of the population served, an analysis of LEP groups 

(including those who need interpreters) by zip code, the number of zip codes where a large 

percentage of residents are LEP, and a group needs assessment that identifies linguistic and 

cultural needs. The OCR guidance suggests that organizations identify non-English languages 

that are likely to be encountered by estimating the number of LEP persons that are eligible for 

services. To obtain this estimate, OCR recommends reviewing census data, client utilization 

data from client files, and data from schools systems and community agencies and 

organizations. 

HRSA specifications for Medicaid managed care contracts suggest that organizations conduct 

an assessment of racial and ethnic minority groups that includes demographic data, including 

literacy and educational levels; epidemiological data; evidence of health disparities; health 

beliefs, including attitudes toward health and illness and traditional medical treatment; and 

health-related behaviors and practices, including the use of alternative medicine and 

practitioners (HRSA, 2000). 

Public comments provided additional recommendations on the type of data that is helpful to 

understand a community and its patient/consumer population. For example, it is helpful to 

collect data on the specific health care needs of the community, such as the number of people 

with asthma or heart disease, or the number of teenagers committing suicide. Collecting data 

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about the cultural factors related to patient needs, attitudes, behaviors, and concerns about 

health and medical care can help organizations plan and implement services. One comment 

suggested that these factors might include the length of time patients/consumers have spent in 

the United States and the number of trips they have taken back to their country of origin. 

Several comments recommended the collection of outcome data, including patient satisfaction, 

access to services, and clinical outcomes such as quality of life and reduction of health 

disparities. Comments also recommended that data collection on racial and ethnic groups in 

the community be expanded to include other diverse cultural groups whose medical needs and 

concerns are not typically addressed by health care organizations. Examples of such groups 

include people with physical or mental disabilities and different sexual orientations. 

To fully understand the surrounding community’s resources, assets, and needs related to 

CLAS, organizations should become knowledgeable about the economic conditions (e.g., 

employment rates), social norms and values (e.g., the community’s health decisionmaking 

process and behaviors), and political structures (e.g., neighborhood governances, planning 

councils) within the community. It is also helpful to identify the formal and informal 

leadership structure in the community; key organizations and institutions; and linkages among 

relevant systems, groups, and individuals (CDC/ATSDR, 1997). HRSA specifications for 

managed care contracts call for health care organizations to identify any public or private 

programs and facilities in the service area that furnish needed services such as health 

education and interpreter services (HRSA, 2000). Learning about community experiences 

dealing with cultural, linguistic, and health issues (e.g., existing coalitions focused on 

HIV/AIDS), as well as successes and failures associated with those experiences, may help 

organizations understand the extent to which the community is willing to become involved in 

other collaborations. It is also important to determine how the community views the health 

care organization and its staff. Understanding these perceptions can help identify problems 

that need to be addressed as well as strengths that can be used to improve services. 

Community mapping is one way to understand and describe a community and its resources. 

This technique identifies human and material resources that can be used to address 

community issues and concerns. Community assets and capabilities might include public 

schools and higher education institutions, cultural organizations, individual businesses and 

business associations, public health agencies, religious organizations, and citizens associations, 

along with individual capacities (McKnight and Kretzmann, 1990). Mapping community 

assets can help health care organizations identify groups and individuals who may be potential 

partners in prioritizing and mobilizing a coordinated response to implement CLAS and 

improve other aspects of health care services. One comment noted that a children’s mental 

health project in the Bronx identified more than 500 community organizations, including 

senior services, faith-based organizations, and schools, that were related in some way to the 

project’s objectives. 

Collaboration to Develop Community Profiles and Needs Assessments 

Many health care organizations have indicated that they have neither the in-house capacity to 

maintain a community profile/needs assessment nor the resources to hire a consultant to 

conduct this CLAS activity. Other organizations already have the framework to collect data 

and learn about their communities but do not yet collect data relevant to CLAS (e.g., 

immigrant and refugee census data). State or local health departments could consider 

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collaborating with health care organizations in their area to jointly develop community 

profiles/needs assessments. For example, health departments could collect quantitative data 

such as basic demographic information on diverse population groups in a specific geographic 

area. The centrally collected data could be made available to local health care organizations, 

which could work with their communities to gather supplemental information about local 

health care needs and assets (e.g., the identification of traditional healers in the community). 

This collaborative approach would avoid the need for organizations to expend limited 

resources in duplicative efforts to collect demographic data on the same populations, yet still 

involve the organizations in the educative process of learning about their patients/consumers. 

Another critical collaboration is the involvement of the community in the design and 

implementation of the community profile and needs assessment. One public comment 

suggested that community partnerships could be useful in assessing the current status of 

existing data. Organizations also can learn from the community what issues it considers 

important and how to make data collection instruments and processes culturally sensitive. 

Another comment urged that people in the community be involved in data collection, 

whatever method is used. This involvement can help allay mistrust among groups in the 

community, such as undocumented immigrants, who may fear reprisals based on information 

collected by the organization. On a related issue, public comments suggested that the 

information collected in accordance with this standard should be shared with the community 

from which it was solicited (see Standard 14). 

Potential Uses for Community Data 

Organizations can use the data collected for community profiles and needs assessments in a 

variety of ways. The data can be useful for customizing services, as well as enhancing specific 

or general assessments of quality and outcomes. Epidemiological information about the 

surrounding community can assist health care organizations in planning for and implementing 

population-based interventions and health education campaigns. Cataloguing the cultural 

needs, resources, and assets of the surrounding community can help an organization plan and 

implement services and linkages with community-based ethnic organizations and private 

providers who can assist with outreach and service delivery to different ethnic groups. 

The State of California requires its Medicaid (Medi-Cal) managed care plans to use 

information collected through group needs assessments to inform and direct both their health 

education and cultural/linguistic programs. This information also has to be integrated with the 

plans’ quality improvement efforts. Thus, the group needs assessment helps create a road map 

for actions that will allow health care plans to meet the needs of their enrollees. 

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STANDARD 12 

COMMUNITY PARTNERSHIPS FOR CLAS (GUIDELINE) 

Standard and Commentary 

12. Health care organizations should develop participatory, collaborative 

partnerships with communities and utilize a variety of formal and informal 

mechanisms to facilitate community and patient/consumer involvement in 

designing and implementing CLAS-related activities. 

The culturally competent organization views responsive service delivery to a community as a 

collaborative process that is informed and influenced by community interests, expertise, and 

needs. Services that are designed and improved with attention to community needs and 

desires are more likely to be used by patients/consumers, thus leading to more acceptable, 

responsive, efficient, and effective care. As described below, this standard addresses two levels 

of consumer/patient and community involvement that are not token in nature, but involve 

working with the community in a mutual exchange of expertise that will help shape the 

direction and practices of the health care organization. 

Patients/consumers and community representatives should be actively consulted and involved 

in a broad range of service design and delivery activities. In addition to providing input on the 

planning and implementation of CLAS activities, they should be solicited for input on broad 

organizational policies, evaluation mechanisms, marketing and communication strategies, staff 

training programs, and so forth. There are many formal and informal mechanisms available 

for this, including participation in governing boards, community advisory committees, ad hoc 

advisory groups, and community meetings as well as informal conversations, interviews, and 

focus groups. 

Health care organizations should also collaborate and consult with community-based 

organizations, providers, and leaders for the purposes of partnering on outreach, building 

provider networks, providing service referrals, and enhancing public relations with the 

community being served. 

Related to Standard 11, health care organizations should involve relevant community groups 

and patients/consumers in the implementation of the community profile and needs 

assessment. 

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Discussion 

Most health care organizations include responsiveness to the community as a part of their 

mission statements, but many struggle with the means and rationale for true partnership 

development with patients/consumers and community representatives. Given the complexity 

of deciphering the cultural beliefs and mores of ethnic communities, health care organizations 

have the potential to benefit greatly from establishing ongoing links and opportunities for 

consultation with representatives from these communities. On the other hand, some 

organizations may fear that community collaboration may also open the door to painful 

criticism and unlimited or unachievable demands. 

If an organization has as its goal the delivery of health services that are appreciated and 

appropriately used by its customers, then input from those individuals is essential to planning, 

implementing, and improving services. Community input provides health care organizations 

with the opportunity to view themselves as they are seen from the outside, and to plan service 

delivery according to the everyday realities of the community. “We all live in our own box,” 

noted one comment, “and we all make assumptions about people who do not live in our box 

because we are not familiar with their situation. We need to have our minds open enough to 

see outside our box and not make assumptions. [Patients/consumers] cannot follow through 

with [advice that is] outside their means, such as taking a daily walk when they live in a 

dangerous neighborhood. That is why community input is crucial, because people will stop 

listening if they hear messages that they ultimately cannot follow through with. Organizations 

will be more effective and will ultimately experience cost savings if they take community input 

into account.” 

Challenges of Authentic Community Involvement 

The challenges of involving consumers and community organizations in delivering health care 

services are both philosophical and practical. The health care organization has to decide 

whether it is developing mechanisms for partnership solely to comply with a requirement, or 

whether it is truly prepared to hear both positive constructive input and critical or angry 

views. Even when the organization’s commitment is authentic, the practical issues can be 

discouraging, especially for organizations that have not previously worked with culturally 

diverse communities. 

In the initial CLAS standards report, the California Medicaid (Medi-Cal) managed care 

requirement for community advisory committees was used as an example of how to 

meaningfully involve consumers in the development and oversight of cultural competence 

activities. Over the years, managed care organizations (MCOs) participating in Medi-Cal have 

been challenged to find authentic ways of involving consumers in the process. While the 

requirements for process and participation are specific, making such advisory committees 

work is not always straightforward. One organization’s perception of success may not be 

viewed so favorably by the community. Consumer advocates have observed that the Medicaid 

population is often challenging to involve in long-term community partnership or planning 

processes. Participants in the Medicaid program frequently lack familiarity with the financial 

and management aspects of MCOs, may not stay on Medicaid very long (resulting in frequent 

turnover on advisory committees), or may not have sufficient time or resources to participate 

fully. On the other hand, several Federal programs have long histories of involving consumers 

in their governance structures and planning. These programs include community and migrant 

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health centers and Head Start, all of which have consumer profiles that are very similar to the 

Medicaid program. 

Often, attention to the small details of support can enable consumers to effectively participate 

in community involvement processes. One comment described a 35-member regional advisory 

committee where Spanish is spoken at the meetings. Some committee participants have 

requested training on meeting protocol and other technical assistance to understand certain 

issues. It is also critical for organizations to provide incentives for patients/consumers to 

participate in community partnership activities. Many low-income working individuals feel 

their circumstances constrain their participation in community meetings. According to one 

comment, “There are many people who have nontraditional working hours, and sometimes 

lose a day of work (which translates into less income for their families) if they participate in 

formal processes for comment. Organizations seeking input should take that into 

consideration and compensate appropriately.” This could include providing monetary stipends, 

transportation reimbursement, childcare, and meals before or after meetings. 

Public comments raised the issue of power imbalances between health care organizations and 

the community as well as between health care organizations and individual 

patients/consumers. Some comments fear that community-based organizations will be 

misused or tokenized by community input processes sponsored by health care organizations. 

With respect to individual patients/consumers, several comments pointed out that some 

members of certain ethnic, age, or gender groups are not always comfortable offering their 

opinions. Some individuals simply believe that they do not have a right to participate in 

communications with their physicians or other health care providers. Resolving these issues 

requires action on many fronts: community leaders can be approached to develop long-term 

advisory relationships; community members can be invited to discussions in which they feel 

safe to raise difficult issues without fear of anger or dismissal; and community and health care 

organizations can work together to educate patients/consumers about how to interact with the 

American health care system. As one comment noted, “There’s a need for a community 

liaison position in health care organizations that sits alongside the chief financial officer and 

other, more traditional keepers of power. We need to get the right people at the table, including 

people who are usually not invited to the table.” 

Methods for Involving the Community 

There are a number of other ways to involve community leaders and patients/consumers in 

partnerships to improve the cultural competence of health care services. For example, 

community leaders could be invited to participate in the ongoing planning and advisory 

groups that design and implement the strategic plan for cultural competence. Many comments 

pointed out that it is also important for health care organizations to go into the community to 

initiate its partnerships. Community leaders and other community-based organizations could 

use their facilities to co-sponsor with the health care organization community forums and 

conversations where patients/consumers can express needs and concerns about health care 

delivery in their area. Churches were frequently mentioned as good partners with which to 

sponsor interactions between health care organizations and the community. Many churches 

also provide social and health services that could be linked to, or supported by, the health care 

organization. In both large and small organizations, including small physician practices, 

individuals from the community who are knowledgeable about cultural health beliefs could 

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serve as advisers and trainers for staff cultural competence training. The health care 

organization or practice could train and hire community members to work as receptionists, 

community outreach workers, and interpreters. When patients/consumers come to the health 

care delivery site, they could be asked to complete short questionnaires about how their needs 

are being met, or they could participate in a semi-structured interview with staff before or 

after their encounters. See Standard 9 for further discussion related to patient surveys. 

Several public comments raised the importance of the “giving back” as part of the process of 

working with the community. “Community members become frustrated when they are asked 

for their input and never hear back about how the input was used and if anything happened 

as a result,” one comment said. Some comments made clear that giving back to the community 

comes from ensuring that the input was used and responsive changes have been made. Others 

felt it important to simply report how the information was delivered and received. Sometimes 

the demonstration of partnership needs to be more creative. “Even if health care organizations 

‘give back’ to their community by having representatives attend a rally to protest the proximity 

of the trash dump, it closes the loop. It demonstrates that the health care organization cares 

enough to prevent future health care problems [in the community].” 

Community Referrals and Liaisons 

Another important issue relates to the development of formal participation and referral 

linkages with ethnic and community-based providers. These types of collaborations may also 

have the effect of assisting mainstream providers with resources and expertise on linguistic 

and cultural competence that otherwise may be difficult and costly to successfully replicate inhouse. Again, as a result of the Medicaid managed care rules in California, some health care 

plans and providers have realized that ongoing patient/consumer education and chronic 

disease or prenatal care management of non-English speaking patients can be difficult and 

time consuming for providers who are not from the patients’ ethnic groups. This realization 

has led to experimentation with the use of community health workers by both providers and 

plans. In light of the limited contact time between patients and clinical providers in most 

health care settings today, the development of community health worker programs may offer 

an effective means of educating and supporting the continuing health management needs of all 

patients (Coye, 1999). 

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STANDARD 13 

COMPLAINT AND GRIEVANCE RESOLUTION (GUIDELINE) 

Standard and Commentary 

13. Health care organizations should ensure that conflict and grie vance resolution 

processes are culturally and linguistically sensitive and capable of identifying, 

preventing, and resolving cross-cultural conflicts or complaints by 

patients/consumers. 

This standard requires health care organizations to anticipate and be responsive to the 

inevitable cross-cultural differences that arise between patients/consumers and the 

organization and its staff. Ideally, this responsiveness may be achieved by integrating cultural 

sensitivity and staff diversity into existing complaint and grievance procedures as well as into 

policies, programs, offices or committees charged with responsibility for patient relations, and 

legal or ethical issues. When these existing structures are inadequate, new approaches may 

need to be developed. 

Patients/consumers who bring racial, cultural, religious, or linguistic differences to the health 

care setting are particularly vulnerable to experiencing situations where those differences are 

not accommodated or respected by the health care institution or its staff. These situations may 

range from differences related to informed consent and advanced directives, to difficulty in 

accessing services or denial of services, to outright discriminatory treatment. Health care 

organizations should ensure that all staff members are trained to recognize and prevent these 

potential conflicts, and that patients are informed about and have access to complaint and 

grievance procedures that cover all aspects of their interaction with the organization. In 

anticipation of patients/consumers who are not comfortable with expressing or acting on their 

own concerns, the organization should have informal and formal procedures such as focus 

groups, staff-peer observation, and medical record review to identify and address potential 

conflicts. 

Among the steps health care organizations can take to fulfill this standard are: providing 

cultural competence training to staff who handle complaints and grievances or other legal or 

ethical conflict issues; providing notice in other languages about the right of each 

patient/consumer to file a complaint or grievance; providing the contact name and number of 

the individual responsible for disposition of a grievance; and offering ombudsperson services. 

Health care organizations should include oversight and monitoring of these culturally or 

linguistically related complaints/grievances as part of the overall quality assurance program for 

the institution. 

Discussion 

It is important to recognize, as many comments noted, that this standard is linked to many 

existing legal requirements. Issues such as grievance procedures, ombudspersons, and 

discrimination policies and procedures are frequently regulated at the Federal and/or state 

level. Many of these policies, however, are designed to be “one size fits all,” and such programs 

may not be used by individuals for culture and language-related concerns or may not be 

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responsive to these issues. Title VI compliance calls for notices to limited English proficiency 

(LEP) patients/consumers about their right to complain about not receiving language 

assistance when needed, as well as their rights to have interpreters and translated materials 

available related to any complaint processes. 

Recognition of Misunderstanding and Bias, and Organizational Solutions 

Often the substance of complaints related to cultural misunderstanding is subtle, and many 

comments pointed out that most health care organizations still struggle with “systemic 

conscious or unconscious bias.” As one comment observed, “Sometimes discrimination 

happens because an organization does not have cultural competence and the necessary policies 

and procedures in place. So it is important to have lawyers involved when policies and 

procedures are being developed to define what is discrimination and violation of rights. 

Racism is still a problem, but it is not as well defined legally as is discrimination. White 

supremacy, black supremacy, and other types of supremacy also are real issues. If people do 

not know how to present themselves respectfully to certain people, the conversation is over. 

Respectful intake engagement needs to be put in procedures and implemented.” 

Clearly, organizations need to address these issues systematically and draw on several types of 

structural and staff resources for assistance. Ideally, such resources would be used to help staff 

recognize and act on emerging cultural conflicts before they rise to the formal complaint level. 

One hospital in the Midwest was providing health care to a community of recent immigrants 

who would not sign informed consent forms because of cultural and religious issues about 

discussing death and dying. The hospital’s legal staff convened a community meeting to 

search for a compromise position that would meet the needs of the community and hospital. 

While the perfect solution was never achieved, the dialogue contributed to better relationships 

and understanding between patients and staff. Another comment recounted a case involving 

an Asian family in which a family member had died. For cultural reasons, the family 

expressed resistance to an autopsy and complained that staff had been rude in responding to 

the family’s concern. It may not always be clear whether such a situation is a complaint or a 

grievance or discrimination, but organizations can foster alternative scenarios that might 

involve calling in a patient advocate or ombudsperson or enlisting the assistance of an ethics 

committee at the first sign of disagreement or conflict. 

Formal institutional policies and procedures to address complaints by patients about unfair or 

discriminatory treatment can provide direction for staff members in their efforts to achieve 

cultural competence. The previous example also highlights the critical role of cultural 

competence training to prepare staff to appropriately respond in the face of cultural 

differences. Procedural guidelines, courses and case study analysis can instruct staff on how to 

listen and respond respectfully when cultural differences arise, how to respond to patient 

complaints, and what cultural issues influence patient dissatisfaction. Organizations may also 

want (or be required) to create programs with an ombudsperson and an ethnically diverse 

staff to proactively address patients rights and protections. Such a program can also provide a 

quality feedback loop to the organization on the effectiveness of ongoing cultural and 

linguistic competency initiatives. 

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Patient Culture/Empowerment Issues 

Health care organizations should not assume that a lack of complaints from 

patients/consumers means that cross-cultural conflict or discrimination is not occurring. 

Often patients/consumers may not recognize that they are being treated inappropriately, or 

they may have fears or cultural beliefs that inhibit complaining, or may not know that they 

have the right to complain. They may also believe that a complaint will be disregarded by the 

institution. Health care organizations need to communicate the concept of patients rights to 

their patient/consumers in a way that recognizes these potential barriers and reassures 

patients about the safety, importance, and validity of the process. The complaint/grievance 

process itself should be understandable, easily accessible, confidential, and transparent. As one 

comment noted, “Clients shouldn’t have to figure out where to go to file a complaint.” 

Linguistic accessibility to notices, forms, and processes is particularly crucial. 

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STANDARD 14 

INFORMATION FOR THE PUBLIC (RECOMMENDATION) 

Standard and Commentary 

14. Health care organizations are encouraged to regularly make available to the 

public information about their progress and successful inno vations in 

implementing the CLAS standards and to provide public notice in their 

communities about the availability of this information. 

Sharing information with the public about a health care organization’s efforts to implement 

the CLAS standards can serve many purposes. It is a way for the organization to communicate 

to communities and patients/consumers about its efforts and accomplishments in meeting the 

CLAS standards. It can help institutionalize the CLAS standards by prompting the 

organization to regularly focus on the extent to which it has implemented each standard. It 

also can be a mechanism for organizations to learn from each other about new ideas and 

successful approaches to implementing CLAS. 

Health care organizations can exercise considerable latitude in both the information they make 

available and the means by which they report it to the public. For example, organizations can 

describe specific organizational changes or new programs that have been instituted in response 

to the standards, CLAS-related interventions or initiatives undertaken, and/or 

accomplishments made in meeting the needs of diverse populations. Organizations that wish 

to provide more in-depth information can report on the data collected about the populations 

and communities served in accordance with Standard 11 and the self-assessment results 

gathered from Standard 9. Organizations should not report scores or use data from selfassessment tools that have not been validated. However, as standard self-assessment 

instruments and performance measures are developed and validated, additional information 

gathered by using these tools could be made available to the public. 

Health care organizations can use a variety of methods to communicate or report information 

about progress in implementing the CLAS standards, including publication of stand-alone 

documents focused specifically on cultural and linguistic competence or inclusion of CLAS 

components within existing organizational reports and documents. Other channels for sharing 

this information include the organization’s member publications; newsletters targeting the 

communities being served; presentations at conferences; newspaper articles; television, radio, 

and other broadcast media; and postings on Web sites. 

Discussion 

Intent of the Standard 

The recommended action in Standard 14 did not appear in any of the source documents for 

the original CLAS standards report. However, its inclusion as a CLAS standard was 

recommended and approved by the National Advisory Committee that met in July 1998. The 

original intent of the standard was to address the accountability of health care organizations to 

their patients/consumers and communities by calling for organizations to publish an annual 

report. In the report accompanying the draft CLAS standards it was noted that an annual 

Office of Minority Health 109 
National Standards for CLAS in Health Car e 

report would benefit the organization by providing a mechanism for reaching out to potential 

patients/consumers and educating providers and staff about the cultural competence goals of 

the organization. The community would benefit from such a document because it could allow 

community residents to understand and monitor the progress that organizations are making 

towards the goal of cultural competence. The idea for the report was stimulated by existing 

efforts such as Harvard Pilgrim Health Care’s publication of a regular “Diversity Report” that 

reviews in a qualitative narrative the goals and progress of the organization related to serving 

diverse populations. 

However, public comments differed on the need for this standard as well as on the purpose 

and nature of the annual report. The National Project Advisory Committee (NPAC) believed 

that the field could not yet support guidelines for formalized and standardized reporting or for 

methodologies that would allow comparisons of data. Nevertheless, the NPAC recognized the 

benefits that reporting on progress toward CLAS offers both the community and the 

organization. Consequently, Standard 14 was retained with a less prescriptive focus. It now 

encourages organizations to provide meaningful information to the public on an ongoing basis 

and gives considerable latitude on how the information is presented. Allowing organizations 

maximum flexibility in meeting this standard is intended to foster both innovation and 

accountability to the community. Although the standard’s commentary emphasizes the 

positive aspects of sharing information, it cautions organizations against reporting scores from 

unvalidated tools that could misrepresent differences between health care organizations. As 

standard self-assessment instruments and performance measures are developed and validated, 

organizations are encouraged to use these tools to provide additional information to the public. 

The Need for Reporting to the Public 

A few commenters believed the annual report was redundant if organizations followed the 

first 13 CLAS standards, particularly Standard 9, which calls for organizational selfassessment. Concerns were raised about the administrative burden and unrealistic time frames 

of such reporting, and one commenter warned that organizations might put more effort into 

preparing a required report than trying to achieve the objectives of the CLAS standards. 

However, comments generally agreed that it was a good idea for organizations to share 

information about progress toward CLAS with the public. For example, it was suggested that 

public disclosure of CLAS-related activities would prompt health care organizations to make 

improvements in this area. It also supports a continuous quality improvement process by 

emphasizing the organization’s ability to respond to patient/consumer needs. The 

development of an annual report could also benefit organizations by helping them learn how 

to reach out to diverse patient populations; communities could benefit from having 

organizations develop programs that match their needs. One commenters stated that the 

public is entitled to meaningful information about the ways that institutions used public funds 

to serve their communities. Other comments emphasized that reports to the public should be 

more than an advertisement for the organization and should include information that was 

relevant, useful, and understandable to the community. 

110 U.S. Department of Health and Human Services 
PART II


Accountability as a Focus of Reporting 

Comments from the public and the NPAC offered varying perspectives on the extent to which 

accountability should be the focus of organizations’ reporting to the public. Although it was 

not the original intent of the draft standard, the call for an annual report raised some concerns 

that the document would become a mandated process that would be linked to reporting to a 

Federal agency. This scenario, in turn, generated fears that the report would be used as a tool 

to monitor for compliance and possible discontinuation of Federal funds. However, some 

commenters viewed accountability as the essence of this standard and saw a report to the 

public as an important tool for community-based organizations to push for change in 

institutions that are not meeting their needs. 

If organizations were to provide the kinds of information that allow for true community 

accountability and informed consumer choice, they might include demographics of the patient 

population; statistics related to interpreter use and availability, translated materials, and staff 

training; and financial reports on CLAS-related expenditures. The National Health Law 

Program recommended that the annual report include self-assessment results gather from 

Standard 9, community data collected in accordance with Standard 11, and the number of 

complaints and their resolution as collected pursuant to Standard 13. Various comments 

suggested that organizations report on performance measures such as patient satisfaction 

ratings, quality improvement and clinical outcome data, and a cost-effectiveness analysis. 

Comparability as a Focus of Reporting 

The usefulness of an annual report depends, in part, on the ability of patients/consumers to 

make decisions based on a comparison of reported results from various health care 

organizations. However, current questions about the availability and variability of 

measurement tools make comparability of such data problematic. Without standardized 

methodologies, data elements, and collection and evaluation processes, every organization 

could have its own approach to evaluating its progress toward what it has defined as CLAS. 

The resulting variability in reporting can be significant. One commenter related that the San 

Francisco Department of Health requests all providers to prepare an annual report on the 

recipients and costs of services, resulting in submitted reports that range in length from 2 to 

65 pages. Until a common set of reporting requirements is developed, organizations could 

explore other ways to enhance the comparability of reported information. For example, certain 

States such as Maryland publish report cards. Health care organizations could request that 

CLAS-related questions be added to this reporting mechanism. 

Office of Minority Health 111 

PART III: METHODOLOGY AND ANALYSIS


PART III


Introduction 

The CLAS standards were developed over three years in a two-stage process sponsored by the 

HHS Office of Minority Health (OMH). The following discussion will briefly review stage 

one of the process, describe in more detail stage two of the process, and summarize the 

changes made to individual standards as a result of public comments received. 

Development of the Draft CLAS Standards: Stage One 

In 1997, the U.S. Department of Health and Human Services’ (HHS) Office of Minority 

Health (OMH) asked Resources for Cross Cultural Health Care and the Center for the 

Advancement of Health to review and compare existing cultural and linguistic competence 

standards and measures in a national context, propose draft national standard language where 

appropriate, assess the information or research needed to relate these guidelines to outcomes, 

and develop an agenda for future work in this area. 

The project methodology for stage one described below was guided by the key tasks and 

questions as requested by OMH. The study objectives that guided this project were as follows: 

• Where are we now in the process of developing cultural and linguistic competence 

standards or performance indicators? 

• Do current attempts converge around common themes and elements and can a consensus 

be developed around draft standards to inform performance indicators? 

• What areas require further investigation and/or additional information to develop a 

consensus? 

The project research questions sought to investigate whether there is sufficient knowledge and 

experience within the health care system in developing cultural and linguistic competence 

standards to form a basis for developing national standards. The following questions served to 

guide the analysis process: 

• What are the common categories of cultural and linguistic competence in existing federal 

and state and other national policy documents? 

• How are performance requirements for cultural and linguistic competence described in 

each category? 

• How do performance requirements compare across similar types of standards (e.g., among 

OCR consent decrees, or Medicaid contracts)? How do they compare across all types of 

standards? 

• Are there discrete elements that appear repeatedly? How frequently for each category? 

• Which elements are the minimum performance requirements in each category? 	Which 

are the most comprehensive? 

• Do the elements converge around particular performance requirements? 

The types of written documents reviewed for this stage one included both technical and policy 

literature. Technical literature, including reports on research studies, and philosophical and 

disciplinary papers served as background materials for guiding the coding of cultural and 

Office of Minority Health 115 
National Standards for CLAS in Health Car e 

linguistic competence elements; these sources are listed in the Bibliography. The policy 

literature included legal reports, federal and state statutory and regulatory documents, 

accreditation guidelines, reports on cultural competence standards or measures, and provider 

contract documents from select state managed care providers. 

In order to address the study questions, 30 policy documents representative of national, 

federal and state agencies that made specific reference to cultural and linguistic competence 

activities were selected for review and analysis. The 30 policy documents were identified 

from various sources including: 

• The National Health Law Program’s (NHeLP) 1998 Ensuring Linguistic Access in Health 

Care Settings: Legal Rights and Responsibilities, and included all Medicaid managed care 

contract language and the summaries of state law requirements addressing language and 

cultural needs from ten regionally representative states. We also conducted a separate 

review of the original contracts selected for inclusion, which are on file in the NHeLPNorth Carolina office. 

• The Center for Health Policy Research’s 1997 publication, Negotiating the New Health 

System: A Nationwide Study of Medicaid Managed Care Contracts . 

• The document entitled “The Office for Civil Rights’ ‘Bottom Lines’ for Linguistic 

Accessibility,” based on NHeLP’s review and synthesis of more than 100 compliance 

agreements or communications from the HHS Office for Civil Rights to health care 

organizations that are recipients of federal funds. As such, we considered it a de facto 

operating standard with respect to the enforcement of Title VI of the Civil Rights Act of 

1964. 

All the policy source documents are listed in an addendum to the Bibliography contained in 

Part IV of this final report. 

Data analysis methods employed both quantitative and qualitative techniques. The 

quantitative methods were driven by content analysis techniques to establish discrete 

measurable units for collating frequency of items within the study documents. The qualitative 

analysis was guided by a content coding process to identify the common categories and an 

initial list of areas judged to be important for inclusion under the cultural and linguistic 

competence thematic clusters. 

A matrix analysis format was used to collate information from the source documents. The 

matrix collated data into two thematic clusters to correspond to (1) linguistic competence 

(covering the area of language access, interpreter and translation services) and (2) cultural 

competence (covering the area of patient, staff and organizational cultural diversity 

management). Originally, each topic area contained twenty elements, which formed the 

vertical axis of the matrix. Each source document was reviewed and details pertaining to 

relevant elements were placed in a cell along the horizontal axis. After revisions, the list of 

elements in each area was reduced to ten and 13, respectively. 

Based on the analysis of data in the matrix, the initial report offered a discussion of the 

frequency and substance pertaining to the final list of elements. The first group of 

recommended standards (21 in all) had cultural and linguistic competence activities as two 

separate categories. The report and first set of recommendations for standards were reviewed 

by a national advisory committee composed of representatives from Federal and state health 

116 U.S. Department of Health and Human Services 
PART III


agencies, provider groups, and academic research, which met in Washington, D.C., in July 

1998. The advisory committee made recommendations for consolidation of the number of 

standards and making the language of each standard more concise, with policy and practice 

implications to be discussed in an accompanying commentary. It also recommended changing 

the terminology for the draft standards to culturally and linguistically appropriate services 

(CLAS) in health care. 

With input gathered from the meeting, a revision of the first set of standards, now reduced to 

14, was presented to a focus group convened at the October 1998 national conference, Quality 

Health Care for Diverse Populations, held in New York City. This version was also distributed 

for limited public comment on the DiversityRx listserv, from which a dozen comments were 

received. A second version was drafted in January 1999, and revised four times between 

February and April 1999 with additional comments from members of the advisory committee. 

The final product, Assuring Cultural Competence in Health Care: Recommendations for National 

Standards and an Outcomes-Focused Research Agendawas submitted to OMH in May 1999. 

Public Comment on and Revision of the CLAS Standards: Stage Two 

OMH determined that the appropriate next step for the draft CLAS standards was to undergo 

a national process of public comment that would result in a broader awareness of HHS 

interest in CLAS in health care, significant input from stakeholder groups on the draft 

standards, and a final revision of the standards and accompanying commentary supported by 

the expertise of a National Project Advisory Committee. To complete this task, OMH 

contracted with IQ Solutions, Inc. and Resources for Cross Cultural Health Care. 

The draft CLAS standards were published in the Federal Registeron December 15, 1999 

(Volume 64, Number 240, pages 70042-70044), and the full report was made available for 

review online at [www.omhrc.gov/CLAS]. Individuals and organizations desiring to comment 

on the standards were encouraged to read the standards and full report, and to send comments 

during the public comment period, which ran from January 1 to April 30, 2000. During this 

period, written comments sent by e-mail and regular mail were received from 104 individuals 

and organizations. 

Individuals also had the opportunity to participate in one of three regional meetings on the 

CLAS standards. The purpose of these one-day meetings was to present information on the 

standards’ development process, and for participants to discuss and provide feedback on issues 

related to the standards themselves or their implementation. Meetings were publicized in the 

Federal Register notice, on the website, and in letters mailed to more than 3,000 stakeholders. 

The meetings were held on January 21, 2000, in San Francisco, California; March 10, 2000, in 

Baltimore, Maryland; and April 7, 2000, in Chicago, Illinois. More than 309 individuals, 

representing themselves or their organizations, participated in the three meetings. All sessions 

of each meeting were audiotaped and transcribed for inclusion in the analysis of public 

comments. 

Following the closure of the public comment period on April 30, 2000, the project team 

(consisting of staff members of OMH, IQ Solutions, Inc., and its subcontractor Resources for 

Cross Cultural Health Care) implemented the following steps to analyze the public comments 

on the CLAS standards received through the three regional meetings, mail, and e-mail. 

The public comments received from all sources were organized according to the following 

Office of Minority Health 117 
National Standards for CLAS in Health Car e 

categories (the numbers used to identify the standards pertain to the numbering system of the 

draft standards. The standards have been reordered in the final revision): 

• General Comments (made on the overall report) 

• Diverse and Culturally Competent Staff (Standards 1, 4, and 5) 

• Consumer and Community Input (Standard 3) 

• Bilingual/Interpreter Services (Standards 6, 7, and 9) 

• Translated Written Materials (Standard 8) 

• The Culturally Competent Organization (Standards 2 and 13) 

• Data Collection and Performance Evaluation (Standards 10, 11, 12, and 14) 

Within these categories, comments were organized by individual standards and within 

standards by major identified themes. Staff reviewed the compilations of comments to identify 

issues and controversies for each standard, and the original comments were organized 

topically for each standard and for the General Comments. The project team then conducted a 

series of meetings to discuss comments on topically grouped sets of standards. Deliberations 

on the CLAS Standards addressed the following set of questions: 

• Is there a powerful consensus from public comments to change the standard in any way? 

If so, what are the issues? 

• Are there any meaningful secondary issues that are so compelling or sensible that they 

need to be considered in terms of changes to the standard? 

• Are there any other issues that should be addressed (e.g., controversies raised by the 

standard) by the CLAS Standards National Project Advisory Committee (NPAC)? 

Deliberations on the general comments addressed the following set of questions: 

• What are the major themes or issues related to the previous process of developing the 

standards, and how should these issues be addressed in the final CLAS standards report? 

• What are major themes related to contextual issues, and how should these themes be 

addressed in the final CLAS standards report? 

• What are major issues related to the subsequent standards development process, and how 

should these themes be addressed? 

National Project Advisory Committee 

Based on the discussions related to these questions, the project team prepared a deliberation 

report for the NPAC that included an analysis of comments on the general comments and each 

standard. Each analysis: 

• Makes recommendations for changes to the standards when clearly indicated by a 

consensus in either public comments or project team deliberations; 

• identifies key themes, issues, and controversies; and 

• provides rationales for changes or controversies that the NPAC is being asked to consider. 

118 U.S. Department of Health and Human Services 
PART III


The CLAS Standards National Project Advisory Committee was composed of 27 individuals 

representing State and Federal agencies, health care organizations, health care professionals, 

consumers, unions, and health care accrediting agencies. A complete list of NPAC members is 

available at [www.omhrc.gov/CLAS] and in the Appendix of this report. The NPAC met with 

the project team in Washington, DC, on July 21-22, 2000. Together, the group: 

• Considered the recommendations proposed in the deliberation report and either concurred 

on the suggested changes to the standard or offered an alternative approach to responding 

to public comments on the issues; 

• examined key issues for which recommendations were not presented in the analysis (due 

to a lack of clear consensus) and, when possible, recommended changes to the standards 

that were responsive to public comments; 

• identified and addressed other issues not raised in the deliberation report; and 

• made recommendations for next steps. 

Following the meeting the project team revised the standards based on the public comments 

and the deliberations of the NPAC, whose members were given the opportunity to review and 

comment on subsequent revisions. No formal consensus was obtained from the NPAC after 

the meeting, although most comments were integrated into the final standards by the project 

team, and the NPAC was given the opportunity to review and comment on the final revisions. 

The final revisions were published in the Federal Registeron December 22, 2000 (Volume 65, 

No. 247, pages 80865 to 80879) as recommended national standards for adoption or 

adaptation by stakeholder organizations and agencies. 

Office of Minority Health 119 

PART IV: BIBLIOGRAPHY AND GLOSSARY


PART IV


BIBLIOGRAPHY 

AAPCHO. State Medicaid managed care: requirements for linguistically appropriate health 

care. Oakland: Association of Asian Pacific Community Health Organizations, 1996. 

ASTHO. ASTHO Bilingual Initiative—report and recommendations: State health agency 

strategies to develop linguistically relevant public health systems. Washington, DC: Association 

of State and Territorial Health Officials, 1992. 

Berlin E, Fowkes W. A teaching framework for cross-cultural health care. The Western Journal 

of Medicine December 1982:139(6):934-938. 

Berman LH, Khan N, Siegel WL. Impacts of Medicaid managed care on immigrants and 

refugees: a best practices review with policy recommendations. Chicago Illinois: Chicago 

Institute on Urban Poverty and Heartland Alliance for Human Needs and Human Rights, 

1996. 

Betancourt J. Establishing the link between cultural competency and racial and ethnic health 

disparities. AHCPR’s User Liaison Program: State Strategies for Promoting Cultural 

Competency in Health Systems: A Workshop for Senior State Health Officials, Charleston, SC, 

June 1999. 

Blackhall LJ, Murphy ST, Frank G, Michel V, Azen S. Ethnicity and attitudes toward patient 

autonomy. Journal of American Medical Association 1995:274(10):820-825. 

Bogomolov B. Personal communication, 1995. 

Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A 

review and conceptual model. Medical Care Research and Review 2000:57:Supplement 

1:181-217. 

California Cultural Competency Task Force. Recommendations for the Medi-Cal Managed Care 

Program. Berkeley, CA: Institute for the Study of Social Change, 1994. 

Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and 

Disease Registry Committee on Community Engagement. Principles of community 

engagement. Atlanta, GA: CDC, 1997. 

Chicago Institute on Urban Poverty. Impacts of Medicaid Managed Care on immigrants and 

refugees: a best practices review with policy recommendations. Chicago: Heartland Alliance 

for Human Needs and Human Rights, 1996. 

Commonwealth of Massachusetts. House Bill 2498: An act to create a Bureau of Interpreter 

Services within the Executive Office of Administration and Finance et seq. Boston: House of 

Representatives, Massachusetts State Legislature, 1989. 

Coye M, Alvarez D. Medicaid managed care and cultural diversity in California. The


Commonwealth Fund, March 1999.


Cross TL, Bazron BJ, Dennis KW, Issacs MR. Towards a culturally competent system of care. 

Vol. 1. Washington, DC: The Georgetown University Child Development Center, 1989. 

Office of Minority Health 123 
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Deutsch C. Corporate diversity, in practice: networks are created and managers made 

accountable. New York Times 1996 Nov 20. 

DiBella A. The role of assumptions in implementing management practices across cultural 

boundaries. Journal of Applied Behavioral Science 1991:29(3):311-327. 

Diversity Rx (www.DiversityRx.org), an electronic clearinghouse of information about 

language and culture in health care. Washington, DC: National Conference of State 

Legislatures and Resources for Cross Cultural Health Care, May 1997 and ongoing. 

Downing B. Professional interpretation: insuring access for refugee and immigrant patients. 

Presentation to the National Conference on Health and Mental Health of Soviet Refugees, 

December 10, 1991. 

Estrada A. Personal communication, April 1999. 

Faden R, Beauchamp T. A history and theory of informed consent. New York: Oxford 

University Press, l986. 

Fortier JP, Chang F, editors. The Henry J. Kaiser Foundation Forum: language barriers to 

health care. Journal of Health Care for the Poor and Underserved 1998 Vol. 9, Supplement. 

Fortier JP. Multicultural health best practices overview for the California Endowment 

Multicultural Health Investment Area. Resources for Cross Cultural Health Care and The 

California Endowment, February 1998. 

Fortier JP. Interpreting for health in the United States: government partnerships with 

communities, interpreters, and providers. In Carr SE et al. The critical link: interpreters in the 

community. Papers from the First International Conference on Interpreting in Legal, Health, 

and Social Service Settings (Geneva Park, Canada, June 1-4, 1995), Philadelphia: John 

Benjamins Press, 1997. 

Ginsberg C, Martin V, Andrulis D, Shaw-Taylor Y, McGregor C. Interpretation and translation 

services in health care: a survey of US public and private teaching hospitals. Washington DC: 

National Public Health and Hospital Institute, March 1995. 

Gonzalez VM, Gonzalez JT, Freeman V, Howard-Pitney B. Health promotion in diverse 

cultural communities: practical guidelines for working in and with diverse cultural 

communities. Palo Alto, CA: Stanford Center for Research in Disease Prevention, 1991. 

Giorgianni SJ, editor. Responding to the challenge of health literacy. The Pfizer Journal, Vol. 5, 

1998. 

Greenhalgh T. Article two in the Research Methods Series. Outside the ivory towers: evidence 

based medicine in the real world. British Journal of General Practice 1998:48:1448-1449. 

Health Resources and Services Administration. Optional purchasing specifications: cultural 

competence in the delivery of services through Medicaid managed care. Sample purchasing 

specifications prepared by the George Washington University Center for Health Services and 

Policy and presented at the meeting of the CLAS National Project Advisory Committee in 

Washington, DC, July 21, 2000. 

HR Explanation and Advice. Diversity management. Alexandria, VA: Research Institute of 

America, Inc., 1997. 

124 U.S. Department of Health and Human Services 
PART IV


Immigrant Refugee Task Force and Lucas P. Policy memo for Health Providers. Chicago, IL: 

Travellers & Immigrants Aid. 

Immigrant Refugee Task Force. Policy platform: for improved health care services to 

immigrants and refugees in public and private health agencies and organizations. Chicago, IL: 

Travellers & Immigrants Aid. 

Issacs MR, Benjamin MP. Towards a culturally competent system of care. Vol. 2. Washington 

DC: The Georgetown University Child Development Center, 1991. 

Jecker NS, Carrese JA, Pearlman RA. Caring for patients in cross-cultural settings. Hastings 

Center Report Jan/Feb 1995:6-13. 

Karp HB, Sutton S. Where diversity training goes wrong. Training July 1993:30-34. 

Katz M. Consumer Protection Workgroup, Secretary’s Quality Initiative, U.S. Department of 

Health and Human Services. Draft report, 1998. 

Katz M. Personal communication, November 1998. 

Kleinman A, Eisenberg L, Good B. Culture, illness and care: clinical lessons, anthropologic and 

cross-cultural research. Annals of Internal Medicine 1978:88:251-258. 

Lavizzo-Mourey R, Mackenzie ER. Cultural competence: essential measurements of quality for 

managed care organizations. Annals of Internal Medicine 1996:124(10):919-921. 

Like RC, Steiner RP, Rubel A. Recommended core curriculum guidelines on culturally 

sensitive and competent health care. Family Medicine 1996:8(4):291-297. 

Lipson JG, Dibble SL, Minarik PA, editors. Culture and nursing care: a pocket guide. San 

Francisco: University of California San Francisco Nursing Press, 1996. 

Louis Harris and Associates. National comparative survey of minority health care. New York: 

The Commonwealth Fund, March 1995. 

McKnight JL, Kretzmann J. Mapping community capacity. Evantson, IL: Center for Urban 

Affairs and Policy Research, Northwestern University, 1990. 

Murawski J. Hispanic woman charges clinic with ‘assault.’ Washington, DC: Legal Times 1993, 

May 24;1. 

NACHO. National Association of County Health Officials Multicultural Health 

Project—recommendations and case study reports. Washington, DC: National Association of 

County Health Officials, 1992. 

OCR. Correspondence to Dennis Oakes, Executive Director, the Academic Medicine and 

Managed Care Forum, from Thomas E. Perez, Director, Office of Civil Rights, U.S. 

Department of Health and Human Services, June 7, 2000. 

Pachter LM. Culture and clinical care: folk illness beliefs and behaviors and their implications 

for health care delivery. Journal of American Medical Association 1994:271(9):690-694. 

Perkins J et al. Ensuring linguistic access in health care settings. Palo Alto: The Henry J. 

Kaiser Family Foundation, April 1998. 

Office of Minority Health 125 
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President’s Advisory Commission on Consumer Protection and Quality in the Health Care 

Industry. Consumer bill of rights and responsibilities. Washington, DC: Advisory Commission 

on Consumer Protection and Quality in the Health Care Industry, 1997. 

Project Hope. Medicaid managed care program access requirements. Washington, DC: 

Prospective Payment Assessment Commission, 1995. 

Randall-David E. Strategies for working with culturally diverse communities and clients. 

Washington DC: Department of Health and Human Services, 1989. 

Reed J. Personal communication, March 20001. 

Richman R. Failure to communicate. The Chicago Reporter 1993, March; 22(3):1, 6-11. 

Riess J, Riddick S. Influencing hospitals to hire bilingual staff: economic carrots and legal 

sticks. Presented at the American Public Health Association Annual Meeting, Montreal, 

Canada, November 1982. 

Rockwell CP. Personal communications. Office for Civil Rights, Region X, HHS, Seattle, WA, 

1991-93. 

Roizner M. A practical guide for the assessment of cultural competence in children’s mental 

health organizations. Boston: Judge Bakerís Childrenís Center, 1996. 

Schmidt RE et al. Limited English proficiency as a barrier to health and social services. 

Washington, DC: Office for Civil Rights, U.S. Department of Health and Human Services, 

1995. 

Sherer J. New waves: hospitals struggle to meet the challenge of multiculturalism now—and 

in the next generation. Hospitals May 1993:20:22-31. 

State of Illinois. Public Act 88-244, The Language Assistance Services Act. Springfield: 

General Assembly of the State of Illinois, 1993. 

State of California. Cultural and linguistic requirements subgroup: recommended standards for 

the Medi-Cal Managed Care Program. Sacramento: State of California Department of Health 

Services, 1993. 

State of California. Letter requesting applications for the Cultural and Linguistics Standards 

Task Force. Sacramento: State of California Department of Health Services, 1995. 

State of California. Request for applications for Medi-Cal Managed Care contractors. 

Sacramento: State of California Department of Health Services, 1994. 

Stokols D. Translating social ecological theory into guidelines for community health 

promotion. American Journal of Health Promotion 1996:10(4):282-298. 

Tirado M. Tools for monitoring cultural competence in health care. San Francisco: Latino 

Coalition for a Healthy California, 1996. 

Trosty RS. Presentation at the Quality Health Care for Culturally Diverse Populations 

conference, New York, October 1-4, 1998. 

USCLHO and USCM. Language and culture in health care: coping with linguistic and cultural 

differences: challenges to local health departments. Washington, DC: United States Conference 

of Local Health Officers and United States Conference of Mayors, 1993. 

126 U.S. Department of Health and Human Services 
PART IV


U.S. Department of Health and Human Services. Policy statement on inclusion of race and 

ethnicity in DHHS data collection activities, October 1997. 

U.S. Department of Health and Human Services. Protecting the privacy of patients’ health 

information: summary of the final regulation (fact sheet), December 20, 2000. 

U.S. House of Representatives Committee on Energy and Commerce. Report 103-501 

accompanying H.R. 3869, Minority Health Improvement Act of 1994, May 11, 1994. 

U.S. House of Representatives. Conference report 103-843 accompanying S. 1569, Minority 

Health Improvement Act of 1994, October 6, 1994. 

U.S. House of Representatives Report 101-804, to accompany H.R. 5702, the Disadvantaged 

Minority Health Improvement Act of 1990, 28-29, 47-48. 

U.S. House of Representatives Report 101-804, to accompany H.R. 5702, the Disadvantaged 

Minority Health Improvement Act of 1990, 28-29, 47-48. 

Veith B, Boone E III. Cultural competency in health care: a snapshot of current issues. 

Washington, DC: Opening Doors, 1996. 

Voelker R. Speaking the languages of medicine and culture. Journal of American Medical 

Association 1995:273(21):1639-1641. 

Washington State Department of Social and Health Services. Language interpreter services and 

translations: bilingual orientation packet. Olympia, WA: Washington State Department of 

Social and Health Services. 

Woloshin S, Bickell NA, Schwartz L, Gany F, Welch HG. Language barriers in medicine in the 

United States. Journal of American Medical Association 1995:273(9):724-728. 

Office of Minority Health 127 
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Addendum: Source Document Master List 

Thirty source documents were reviewed and analyzed for language on linguistic and cultural 

competence standards or measures. Twenty of these documents were accessed from the 

National Health Law Program’s (NHeLP) 1998 publication, Ensuring Linguistic Access in 

Health Care Settings: Legal Rights and Responsibilities, and included all Medicaid managed care 

contract language and the summaries of state law requirements addressing language and 

cultural needs from ten regionally representative states. We also conducted a separate review 

of the original contracts selected for inclusion, which are on file in the NHeLP-North Carolina 

office. Medicaid managed care language was also partly culled from the Center for Health 

Policy Research’s 1997 publication, Negotiating the New Health System: A Nationwide Study 

of Medicaid Managed Care Contracts. The document entitled “The Office of Civil Rights’ 

‘Bottom Lines’ for Linguistic Accessibility” is based on NHeLP’s review and summary of more 

than 100 compliance agreements or communications from the HHS Office for Civil Rights to 

providers who are recipients of federal funds. The Consumer Bill of Rights, contained in 

Quality First: Better Health Care for All Americans. Final Report to the President of the United 

States from The President’s Advisory Commission on Consumer Protection and Quality in the 

Health Care Industry, has been adopted as policy guidance for all Federal health care 

programs. 

The source documents are as follows: 

(1) Department of Health and Human Services, Office of Civil Rights. Guidance 

Memorandum: Title VI Prohibition Against National Origin Discrimination-Persons with 

Limited-English Proficiency (1998). 

(2) State of California, Health Welfare Agency, Department of Mental Health. Addendum for 

Implementation Plan for Phase II Consolidation of Medi-Cal Specialty Mental Health ServicesCultural Competence Plan Requirements(1997). 

(3) New York State, Office of Mental Health. Cultural and Linguistic Competency Standards 

(1997). 

(4) Substance Abuse and Mental Health Services Administration, Center for Mental Health 

Services. Cultural Competence Standards in Managed Mental Health Care for Four 

Underserved/Underrepresented Racial/Ethnic Groups (1997). 

(5) California Department of Health Services. Medi-Cal Managed Care Local Initiative/MediCal Managed Care Requirements Evaluation of Cultural and Linguistic Requirements. 

(6) National Committee on Quality Assurance. Availability of Language Interpretation 

Services/Summary of Changes from HEDIS 2.5 and/or Medicaid HEDIS, 3.0, Volume 2 

(1997). 

(7) National Health Law Program. Ensuring Linguistic Access in Health Care Settings: Legal 

Rights and Responsibilities, “Office of Civil Right’s Bottom Lines for Linguistic 

Accessibility,”1998. 

Medicaid managed care contract language for 

(8) California; (9) Colorado; (10) Florida; (11) Hawaii; (12) Massachusetts; (13) Nebraska; 

(14) Pennsylvania; (15) Texas; (16) Vermont; (17) Washington. 

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PART IV


Summary of state law requirements addressing language and cultural needs for 

(18) California; (19) Colorado; (20) Hawaii; (21) Massachusetts; (22) Florida; (23) 

Pennsylvania; (24) Texas; (25) Vermont; (26) Washington. 

(27) The Commonwealth of Massachusetts, Division of Medical Assistance. Contract 

Requirements for Cultural Competence (1997). 

(28) Joint Commission on Accreditation of Health Care Organizations’ Comprehensive 

Accreditation Manuals for: Ambulatory Care, Behavioral Health Care, Health Care Networks, 

Home Care, Hospitals, and Long Term Care (selections). 

(29) The Consumer Bill of Rights, contained in Quality First: Better Health Care for All 

Americans. Final Report to the President of the United States. The President’s Advisory 

Commission on Consumer Protection and Quality in the Health Care Industry, November 

1997. 

(30) Medicare+Choice regulations. 

Office of Minority Health 129 

PART IV


GLOSSARY 

CLAS standards The collective set of CLAS mandates, guidelines, and recommendations 

issued by the HHS Office of Minority Health intended to inform, guide, and facilitate required 

and recommended practices related to culturally and linguistically appropriate health services. 

community Any set of persons within the society that differs from other sets due to 

demographic, economic or social characteristics such as age, sex, education level, race, religion, 

income level, lifestyle, beliefs, etc. 

cultural competence Having the capacity to function effectively as an individual and an 

organization within the context of the cultural beliefs, behaviors and needs presented by 

consumers and their communities. 

culture “The thoughts, communications, actions, customs, beliefs, values, and institutions of 

racial, ethnic, religious, or social groups. Culture defines how health care information is 

received, how rights and protections are exercised, what is considered to be a health problem, 

how symptoms and concerns about the problem are expressed, who should provide treatment 

for the problem, and what type of treatment should be given. In sum, because health care is a 

cultural construct, arising from beliefs about the nature of disease and the human body, 

cultural issues are actually central in the delivery of health services treatment and preventive 

interventions. By understanding, valuing, and incorporating the cultural differences of 

America’s diverse population and examining one’s own health-related values and beliefs, 

health care organizations, practitioners, and others can support a health care system that 

responds appropriately to, and directly serves the unique needs of populations whose cultures 

may be different from the prevailing culture” (Katz, Michael. Personal communication, 

November 1998). 

culturally and linguistically appropriate services Health care services that are respectful 

of and responsive to cultural and linguistic needs. 

cultural and linguistic competence “Cultural and linguistic competence is a set of congruent 

behaviors, attitudes, and policies that come together in a system, agency, or among 

professionals that enables effective work in cross-cultural situations. ‘Culture’ refers to 

integrated patterns of human behavior that include the language, thoughts, communications, 

actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. 

‘Competence’ implies having the capacity to function effectively as an individual and an 

organization within the context of the cultural beliefs, behaviors, and needs presented by 

consumers and their communities” (Based on Cross, T., Bazron, B., Dennis, K., & Isaacs, M., 

(1989). Towards A Culturally Competent System of Care Volume I. Washington, DC: 

Georgetown University Child Development Center, CASSP Technical Assistance Center). 

cultural sensitivity The ability to be appropriately responsive to the attitudes, feelings, or 

circumstances of groups of people that share a common and distinctive racial, national, 

religious, linguistic or cultural heritage. 

discrimination Treatment or consideration based on class or category rather than individual 

merit. 

ethnicity The characteristic of a group of people that share a common and distinctive racial 

national, religious, linguistic or cultural heritage. 

Office of Minority Health 131 
National Standards for CLAS in Health Car e 

health care organization Any public or private institution involved in any aspect of


delivering health care services.


health disparities Differences in health across individuals in the population.


health maintenance organization (HMO) A type of managed care organization that


provides comprehensive medical care for a predetermined annual fee per enrollee.


Interpreter A person who translates orally from one language to another.


ombudsperson A person who investigates complaints, reports findings, and mediates fair


settlements, especially between aggrieved parties.


patients/consumers Individuals, including accompanying family members, guardians, or


companions, seeking physical or mental health care services, or other health-related services.


quality of life Factors that are considered important by patients such as environmental


comfort, security, interpersonal relations, and autonomy of making decisions.


race A local geographic or global human population distinguished as a more or less distinct


group by genetically transmitted physical characteristics. A group of people united or classified


together on the basis of common history, nationality, or geographic distribution.


religion A set of beliefs, values and practices based on the teachings of a spiritual leader.


sexual orientation The direction of one’s sexual interest toward members of the same,


opposite, or both sexes.


staff Individuals employed directly by a health care organization, as well as those


subcontracted or affiliated with the organization.


strategic plan An approach that incorporates elements of all kinds of planning, helps


respond to questions and helps to identify potential problems that may arise over time.


training to make proficient with specialized instruction and practice.


References 

World Health Report 2000, Quick reference Compendium of Selected Key Terms. 

[http://www.who.int]. 

Spector, Rachel E., Cultural Diversity in Health and Illness. Prentice Hall, Inc. 2000. 

Kreps, Gary, Kunimoto, Elizabeth, Effective Communication in Multicultural Health Care 

Settings. Sage Publications, 1994. 

American Heritage Dictionary of the English language. 

Webster’s Collegiate Dictionary. 

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