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

O ffice of Minority Health 

National Standards for 

Culturally and Linguistically 

Appropriate Services in 

Health Care 

EXECUTIVE SUMMARY 

March 2001 

Washington, D.C. 
National Standards for Culturally and Linguistically


Appropriate Services 


in Health Care


EXECUTIVE SUMMARY 

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 

STANDARDS


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 iii 

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 v 
National Standards for CLAS in Health Car e 

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. 

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


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. 

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

• 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. 

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


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). 

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

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 

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


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 

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

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. 

xii U.S. Department of Health and Human Services 
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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 

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

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 

xiv U.S. Department of Health and Human Services 
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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 

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

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 

xvi U.S. Department of Health and Human Services 
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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. 

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

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. 

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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, 

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

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. 

xx U.S. Department of Health and Human Services 
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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 devlop 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, 

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

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 

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


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 

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

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]. 

xxiv U.S. Department of Health and Human Services 

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 vii 

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 1 
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 

2 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 3 

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 5 
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. 

6 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 7 
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. 

8 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 9 
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. 

10 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 11 
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. 

12 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 13 
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. 

14 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 15 
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. 

16 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 17 
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. 

18 U.S. Department of Health and Human Services