National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

National Standards for Culturally and Linguistically 

Appropriate Services in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS 

Policy and Practice

Office of Minority Health

U.S. Department of Health and Human Services

April 2013
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

i

Table of Contents

Acknowledgments................................................................................................................. 7

Executive Summary............................................................................................................... 8

National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care .... 13

The Case for the Enhanced National CLAS Standards........................................................... 14

Respond to Demographic Changes .....................................................................................................15

Eliminate Health Disparities ................................................................................................................16

Improve Quality of Services and Care.................................................................................................17

Meet Legislative, Regulatory, and Accreditation Mandates .................................................................. 17

Gain a Competitive Edge in the Market Place...................................................................................... 19

Decrease the Risk of Liability ..............................................................................................................19

The Enhanced National CLAS Standards .............................................................................. 21

The Standards....................................................................................................................................21

Purpose..............................................................................................................................................21

Audience ............................................................................................................................................21

Components of the Standards ............................................................................................................23

Strategies for Implementation ............................................................................................................23

Enhancements to the National CLAS Standards................................................................... 24

Culture...............................................................................................................................................24

Health ................................................................................................................................................27

Health and Health Care Organizations ................................................................................................27

Individuals and Groups.......................................................................................................................28

Statement of Intent............................................................................................................................28

Clarity and Action ...............................................................................................................................29

Standards of Equal Importance ..........................................................................................................29

Principal Standard and Three Enhanced Themes ................................................................................ 30

New Standard: Organizational Governance and Leadership................................................................. 33
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

ii

Looking Ahead: The Future and the National CLAS Standards.............................................. 34

Continued Enhancements ...................................................................................................................34

State and Federal Legislation..............................................................................................................34

Support and Guidance........................................................................................................................34

Bibliography........................................................................................................................ 36

The Blueprint ...................................................................................................................... 43

Standard 1: Provide Effective, Equitable, Understandable, and Respectful Quality Care and 

Services .............................................................................................................................. 44

Standard 1 .........................................................................................................................................44

Purpose..............................................................................................................................................44

Components of the Standard..............................................................................................................44

Strategies for Achievement of the Principal Standard.......................................................................... 48

Resources ..........................................................................................................................................48

Bibliography .......................................................................................................................................49

Standard 2: Advance and Sustain Governance and Leadership that Promotes CLAS and 

Health Equity ...................................................................................................................... 52

Standard 2 .........................................................................................................................................52

Purpose..............................................................................................................................................52

Components of the Standard..............................................................................................................52

Strategies for Implementation ............................................................................................................56

Resources ..........................................................................................................................................57

Bibliography .......................................................................................................................................58

Standard 3: Recruit, Promote, and Support a Diverse Governance, Leadership, and Workforce

........................................................................................................................................... 60

Standard 3 .........................................................................................................................................60

Purpose..............................................................................................................................................60

Components of the Standard..............................................................................................................60

Strategies for Implementation ............................................................................................................62

Resources ..........................................................................................................................................63
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

iii

Bibliography .......................................................................................................................................64

Standard 4: Educate and Train Governance, Leadership, and Workforce in CLAS................. 66

Standard 4 .........................................................................................................................................66

Purpose..............................................................................................................................................66

Components of the Standard..............................................................................................................66

Strategies for Implementation ............................................................................................................68

Resources ..........................................................................................................................................69

Bibliography .......................................................................................................................................70

Standard 5: Offer Communication and Language Assistance ............................................... 72

Standard 5 .........................................................................................................................................72

Purpose..............................................................................................................................................72

Components of the Standard..............................................................................................................72

Strategies for Implementation ............................................................................................................76

Resources ..........................................................................................................................................76

Bibliography .......................................................................................................................................77

Standard 6: Inform Individuals of the Availability of Language Assistance.......................... 79

Standard 6 .........................................................................................................................................79

Purpose..............................................................................................................................................79

Components of the Standard..............................................................................................................79

Strategies for Implementation ............................................................................................................81

Resources ..........................................................................................................................................83

Bibliography .......................................................................................................................................83

Standard 7: Ensure the Competence of Individuals Providing Language Assistance ............ 85

Standard 7 .........................................................................................................................................85

Purpose..............................................................................................................................................85

Components of the Standard..............................................................................................................85

Strategies for Implementation ............................................................................................................88

Resources ..........................................................................................................................................89
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

iv

Bibliography .......................................................................................................................................90

Standard 8: Provide Easy-to-Understand Materials and Signage ......................................... 93

Standard 8 .........................................................................................................................................93

Purpose..............................................................................................................................................93

Components of the Standard..............................................................................................................93

Strategies for Implementation ............................................................................................................95

Resources ..........................................................................................................................................96

Bibliography .......................................................................................................................................97

Standard 9: Infuse CLAS Goals, Policies, and Management Accountability Throughout the 

Organization’s Planning and Operations.............................................................................. 99

Standard 9 .........................................................................................................................................99

Purpose..............................................................................................................................................99

Components of the Standard..............................................................................................................99

Strategies for Implementation .......................................................................................................... 100

Resources ........................................................................................................................................ 101

Bibliography ..................................................................................................................................... 102

Standard 10: Conduct Organizational Assessments........................................................... 103

Standard 10 ..................................................................................................................................... 103

Purpose............................................................................................................................................ 103

Components of the Standard............................................................................................................ 103

Strategies for Implementation .......................................................................................................... 105

Resources ........................................................................................................................................ 106

Bibliography ..................................................................................................................................... 107

Standard 11: Collect and Maintain Demographic Data....................................................... 108

Standard 11 ..................................................................................................................................... 108

Purpose............................................................................................................................................ 108

Components of the Standard............................................................................................................ 108

Strategies for Implementation .......................................................................................................... 113
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

v

Resources ........................................................................................................................................ 115

Bibliography ..................................................................................................................................... 116

Standard 12: Conduct Assessments of Community Health Assets and Needs..................... 118

Standard 12 ..................................................................................................................................... 118

Purpose............................................................................................................................................ 118

Components of the Standard............................................................................................................ 118

Strategies for Implementation .......................................................................................................... 120

Resources ........................................................................................................................................ 122

Bibliography ..................................................................................................................................... 122

Standard 13: Partner with the Community ........................................................................ 124

Standard 13 ..................................................................................................................................... 124

Purpose............................................................................................................................................ 124

Components of the Standard............................................................................................................ 124

Strategies for Implementation .......................................................................................................... 125

Resources ........................................................................................................................................ 126

Bibliography ..................................................................................................................................... 127

Standard 14: Create Conflict and Grievance Resolution Processes..................................... 129

Standard 14 ..................................................................................................................................... 129

Purpose............................................................................................................................................ 129

Components of the Standard............................................................................................................ 129

Strategies for Implementation .......................................................................................................... 130

Resources ........................................................................................................................................ 131

Bibliography ..................................................................................................................................... 132

Standard 15: Communicate the Organization’s Progress in Implementing and Sustaining 

CLAS ................................................................................................................................. 133

Standard 15 ..................................................................................................................................... 133

Purpose............................................................................................................................................ 133

Components of the Standard............................................................................................................ 133
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

vi

Strategies for Implementation .......................................................................................................... 134

Resources ........................................................................................................................................ 135

Bibliography ..................................................................................................................................... 136

Appendix A: Glossary ........................................................................................................ 137

Bibliography ..................................................................................................................................... 148

Appendix B: National CLAS Standards Enhancement Initiative.......................................... 155

Background...................................................................................................................................... 155

Goals................................................................................................................................................ 155

Development Process ....................................................................................................................... 156

Public Comment............................................................................................................................... 157

National Project Advisory Committee ................................................................................................ 158

Appendix C: National Project Advisory Committee ............................................................ 162

Appendix D: Crosswalk – National CLAS Standards 2000 and 2012 ................................... 165

Appendix E: Resources...................................................................................................... 169

List of Figures and Tables

Figure 1: State Legislation......................................................................................................................18

Figure 2: Interrelationship of Aspects of Culture..................................................................................... 27

Figure 3: Enhanced National CLAS Standards’ Themes........................................................................... 31

Figure 4: Phases of the National CLAS Standards Enhancement Initiative............................................. 156

Figure 5: Advisory Committee Meetings ............................................................................................... 159

Table 1: Blueprint Chapter Structure......................................................................................................43

Table 2: Examples of Promoting CLAS Through Policy and Practice........................................................ 54

Table 3: Interpreting and Translating.....................................................................................................73

Table 4: A Process for Collecting Data.................................................................................................. 114
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Acknowledgments 7

Acknowledgments

This document is the result of a multiyear process that involved many individuals across the country. We 

extend our appreciation to them:

o The National Project Advisory Committee (Advisory Committee) members, for their generosity in 

sharing their time and expertise and their tireless dedication in the review of numerous drafts of 

terminology, documents, and the enhanced National CLAS Standards. A complete list of the 

Advisory Committee members appears in Appendix C.

o The individuals and organizations who participated in the public comment period, either by 

attending a public comment meeting or by providing online or written submissions. Your input 

helped to inform the enhancements to the National CLAS Standards, originally released in 2000.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Executive Summary 8

Executive Summary

Health equity is the attainment of the highest level of health for all people (U.S. Department of Health 

and Human Services [HHS] Office of Minority Health [OMH], 2011). Currently, individuals across the 

United States from various cultural backgrounds are unable to attain their highest level of health for 

several reasons, including the social determinants of health, or those conditions in which individuals are 

born, grow, live, work, and age (World Health Organization [WHO], 2012), such as socioeconomic status, 

education level, and the availability of health services (HHS Office of Disease Prevention and Health 

Promotion [ODPHP], 2010a). Though health inequities are directly related to the existence of historical 

and current discrimination and social injustice, one of the most modifiable factors is the lack of culturally 

and linguistically appropriate services, broadly defined as care and services that are respectful of and 

responsive to the cultural and linguistic needs of all individuals.

Health inequities result in disparities that directly affect the quality of life for all individuals. Health 

disparities adversely affect neighborhoods, communities, and the broader society, thus making the issue 

not only an individual concern but also a public health concern. In the United States, it has been 

estimated that the combined cost of health disparities and subsequent deaths due to inadequate and/or 

inequitable care is $1.24 trillion (LaVeist, Gaskin, & Richard, 2009). Culturally and linguistically 

appropriate services are increasingly recognized as effective in improving the quality of care and services 

(Beach et al., 2004; Goode, Dunne, & Bronheim, 2006). There are numerous ethical and practical reasons 

why providing culturally and linguistically appropriate services in health and health care is necessary, 

including the following, which have been identified by the National Center for Cultural Competence 

(Cohen & Goode, 1999, revised by Goode & Dunne, 2003):

1. To respond to current and projected demographic changes in the United States.

2. To eliminate long-standing disparities in the health status of people of diverse racial, ethnic 

and cultural backgrounds.

3. To improve the quality of services and primary care outcomes.

4. To meet legislative, regulatory and accreditation mandates.

5. To gain a competitive edge in the market place.

6. To decrease the likelihood of liability/malpractice claims.

The six reasons for the implementation of cultural competency as described by the National Center for 

Cultural Competence fall into two frequently cited overarching philosophies: one that pertains to social 

justice and the other that pertains to standards of business. The social justice philosophy emphasizes 

diversity and the improvement of services to underserved populations, while the standards of business 

philosophy focuses on strengthening business practices and business development.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Executive Summary 9

The enhanced National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health 

and Health Care, known as the enhanced National CLAS Standards, from the Office of Minority Health at 

the U.S. Department of Health and Human Services are intended to advance health equity, improve 

quality, and help eliminate health care disparities by providing a blueprint for individuals and health and 

health care organizations to implement culturally and linguistically appropriate services. The enhanced 

National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities 

(HHS, 2011) and the National Stakeholder Strategy for Achieving Health Equity (National Partnership for 

Action to End Health Disparities, 2011a), which aim to promote health equity through providing clear 

plans and strategies to guide collaborative efforts that address racial and ethnic health disparities across 

the country. Adoption of these Standards will help advance better health and health care in the United 

States.

The enhanced National CLAS Standards are built upon the groundwork laid by the original National CLAS 

Standards, developed in 2000 by the HHS Office of Minority Health. The original National CLAS Standards 

provided guidance on cultural and linguistic competency, with the ultimate goal of reducing racial and 

ethnic health care disparities. Over the past decade, the original National CLAS Standards have served as 

catalyst and conduit for efforts to improve the quality of care and achieve health equity (e.g., Diamond, 

Wilson-Stronks, & Jacobs, 2010; Joint Commission, 2010; Kairys & Like, 2006).

The HHS Office of Minority Health undertook the National CLAS Standards Enhancement Initiative from 

2010 to 2012 to recognize the nation’s increasing diversity, to reflect the tremendous growth in the fields 

of cultural and linguistic competency over the past decade, and to ensure relevance with new national 

policies and legislation, such as the Affordable Care Act. A decade after the publication of the original 

National CLAS Standards, there is still much work to be done. Racial and ethnic disparities in health and 

health care remain a significant public health issue, despite advances in health care technology and 

delivery, even when factors such as insurance coverage, income, and educational attainment are taken 

into account (American College of Physicians, 2010; Griffith, Yonas, Mason, & Havens, 2010). Cultural 

and linguistic competency strives to improve the quality of care received and to reduce disparities 

experienced by racial and ethnic minorities and other underserved populations (Saha, Beach, & Cooper, 

2008). Through the National CLAS Standards Enhancement Initiative, a new benchmark is being 

established for culturally and linguistically appropriate services to improve the health of all individuals.

The National CLAS Standards Enhancement Initiative’s development process, described in detail in 

Appendix B, was informed by three primary sources: public comment, a National Project Advisory 

Committee, and a systematic literature review. These three sources of data informed the scope and 

direction of the Enhancement Initiative, and, ultimately, the enhanced National CLAS Standards. For 

example, the majority of public comments indicated that while the original National CLAS Standards met 

the intended needs as a whole, additional context was needed regarding the Standards’ focus and 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Executive Summary 10

purpose, as well as more clearly defined key terminology. Additional comments suggested that the 

organizations targeted for implementing the National CLAS Standards should be expanded and that 

additional guidance regarding implementation should be provided.

The data collected from public comment, the National Project Advisory Committee, and the systematic 

literature review showed strong support for expanding the key concepts of culture and health, which 

serve as the conceptual underpinnings of the National CLAS Standards. Adopting a more comprehensive 

conceptualization of health requires, by extension, a more inclusive recognition of the variety of 

professionals and organizations providing the related care and services. The enhancements related to this 

are as follows:

o Culture is defined as the integrated pattern of thoughts, communications, actions, customs, 

beliefs, values, and institutions associated, wholly or partially, with racial, ethnic, or linguistic 

groups, as well as with religious, spiritual, biological, geographical, or sociological characteristics. 

Culture is dynamic in nature, and individuals may identify with multiple cultures over the course 

of their lifetimes. This definition is adapted from other widely accepted definitions of culture (i.e., 

Gilbert, Goode, & Dunne, 2007; HHS OMH, 2005) and attempts to reflect the complex nature of 

culture, as well as the various ways in which culture has been defined and studied across 

multiple disciplines.

o Health is understood to encompass many aspects, including physical, mental, social, and 

spiritual well-being (HHS Indian Health Services [IHS], n.d.; HHS Office of the Surgeon General 

[OSG] & National Action Alliance for Suicide Prevention, 2012; WHO, 1946). The World Health 

Organization also notes that health is “not merely the absence of disease or infirmity” (WHO, 

1946). Health status occurs along a continuum and therefore can range from poor to excellent. 

The advancement of health equity allows individuals to experience better health over the course 

of their life spans.

o Audience The enhanced National CLAS Standards reference both health and health care 

organizations to acknowledge those working not only in health care settings, such as hospitals, 

clinics, and community health centers, but also in organizations that provide services such as 

behavioral and mental health, public health, emergency services, and community health. Any 

organization addressing individual or community health, health care, or well-being can benefit 

from the adoption and implementation of the National CLAS Standards.

To further reflect the more inclusive nature of the enhanced National CLAS Standards, the 

enhanced Standards use the terminology individuals and groups in lieu of patients and 

consumers. Individuals and groups encompass patients, consumers, clients, recipients, families, 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Executive Summary 11

caregivers, and communities. Therefore, the term individuals and groups includes anyone 

receiving services from a health or health care organization.

Thus, the enhanced National CLAS Standards incorporate broader definitions of culture and health and 

aim to reach a broader audience, in an effort to ensure that every individual has the opportunity to 

receive culturally and linguistically appropriate health care and services.

The data collected from public comment, the National Project Advisory Committee, and the systematic 

literature review also informed several enhancements to the structure and content of the National CLAS 

Standards, as follows (see Appendix D for a comparison between the original and enhanced National 

CLAS Standards):

o Statement of Intent: The enhanced National CLAS Standards include an introductory 

statement:

“The National CLAS Standards are intended to advance health equity, improve quality, and help 

eliminate health care disparities by establishing a blueprint for health and health care 

organizations to:”

The addition of the statement of intent ties the culturally and linguistically competent policies and 

practices posed in the enhanced National CLAS Standards directly to the goals of advancing 

health equity, improving quality, and eliminating health care disparities.

o Clarity and Action: Each of the National CLAS Standards was revised for greater clarity and 

focus. In addition, the wording of each of the 15 Standards now begins with an action word to 

emphasize how the desired goal may be achieved.

o Standards of Equal Importance: The original National CLAS Standards designated each 

Standard as a recommendation, mandate, or guideline. The enhanced National CLAS Standards, 

however, promote collective adoption of all Standards to promote optimal health and well-being 

of all individuals. Each of the 15 Standards should be viewed as an equally important guideline to 

advance health equity, improve quality, and help eliminate health care disparities.

o Principal Standard and Three Enhanced Themes: The enhanced Standards have been 

reorganized to address feedback obtained from the Enhancement Initiative and to improve their 

overall intention, clarity, and practicality. The enhanced National CLAS Standards elevate the 

previous Standard 1 to the status of Principal Standard and reframe the three themes. The 

names of the three themes have been updated both to clarify intent and to broaden the scope of 

their interpretation and application.

• Principal Standard: Standard 1 has been made the Principal Standard with the 

understanding that it frames the essential goal of all of the Standards, and if the other 14 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Executive Summary 12

Standards are adopted, implemented, and maintained, then the Principal Standard will be 

achieved.

• Theme 1: Governance, Leadership, and Workforce — Changing the name of Theme 1 

from Culturally Competent Care to Governance, Leadership, and Workforce provides 

greater clarity on the specific locus of action for each of these Standards and emphasizes 

the importance of CLAS implementation as a systemic responsibility, requiring the 

endorsement and investment of leadership, and the support and training of all individuals 

within an organization.

• Theme 2: Communication and Language Assistance — Changing the name of Theme 2 

from Language Access Services to Communication and Language Assistance broadens 

the understanding and application of appropriate services to include all communication 

needs and services, e.g., sign language, braille, oral interpretation, and written 

translation.

• Theme 3: Engagement, Continuous Improvement, and Accountability — Changing the 

name of Theme 3 from Organizational Supports to Engagement, Continuous 

Improvement, and Accountability underscores the importance of establishing individual 

responsibility for ensuring that CLAS is supported, while maintaining that effective 

delivery of CLAS demands action across organizations.

o New Standard: Organizational Governance and Leadership: The enhanced National CLAS 

Standards emphasize the importance of CLAS being integrated throughout an organization. This 

requires a bottom-up and a top-down approach to advancing and sustaining CLAS. Organizational 

governance and leadership are key to ensuring the successful implementation and maintenance 

of CLAS. In recognition of this, the enhanced National CLAS Standards include a new Standard 

focused on the role of governance and leadership as it relates to CLAS. A complete list of all 15 

enhanced National CLAS Standards, including the new Standard, can be found at the end of this 

executive summary.

This document, the National Standards for Culturally and Linguistically Appropriate Services in Health and 

Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice (The Blueprint), offers a 

user-friendly format for providing comprehensive — but by no means exhaustive — information on each 

Standard. The Blueprint is an implementation guide for advancing and sustaining culturally and 

linguistically appropriate services within health and health care organizations. The Blueprint dedicates one 

chapter to each of the 15 Standards. These chapters review the Standard’s purpose, components, and 

strategies for implementation. In addition, each chapter provides a list of resources that provide 

additional information and guidance on that Standard.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Executive Summary 13

National Standards for Culturally and Linguistically Appropriate 

Services in Health and Health Care 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Principal Standard:

1. Provide effective, equitable, understandable, and respectful quality care and services that are 

responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, 

and other communication needs.

Governance, Leadership, and Workforce:

2. Advance and sustain organizational governance and leadership that promotes CLAS and health 

equity through policy, practices, and allocated resources.

3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and 

workforce that are responsive to the population in the service area.

4. Educate and train governance, leadership, and workforce in culturally and linguistically 

appropriate policies and practices on an ongoing basis.

Communication and Language Assistance:

5. Offer language assistance to individuals who have limited English proficiency and/or other 

communication needs, at no cost to them, to facilitate timely access to all health care and 

services.

6. Inform all individuals of the availability of language assistance services clearly and in their 

preferred language, verbally and in writing.

7. Ensure the competence of individuals providing language assistance, recognizing that the use of 

untrained individuals and/or minors as interpreters should be avoided.

8. Provide easy-to-understand print and multimedia materials and signage in the languages 

commonly used by the populations in the service area.

Engagement, Continuous Improvement, and Accountability:

9. Establish culturally and linguistically appropriate goals, policies, and management accountability, 

and infuse them throughout the organization’s planning and operations.

10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLASrelated measures into measurement and continuous quality improvement activities.

11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact 

of CLAS on health equity and outcomes and to inform service delivery.

12. Conduct regular assessments of community health assets and needs and use the results to plan 

and implement services that respond to the cultural and linguistic diversity of populations in the 

service area.

13. Partner with the community to design, implement, and evaluate policies, practices, and services 

to ensure cultural and linguistic appropriateness.

14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate 

to identify, prevent, and resolve conflicts or complaints.

15. Communicate the organization’s progress in implementing and sustaining CLAS to all 

stakeholders, constituents, and the general public.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

The Case for the Enhanced National CLAS Standards 14

The Case for the Enhanced National CLAS Standards

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

— Dr. Martin Luther King, Jr.

Health equity is the attainment of the highest level of health for all people (HHS OMH, 2011). Currently, 

individuals across the United States from various cultural backgrounds are unable to attain their highest 

level of health for several reasons, including the social determinants of health, or those conditions in 

which individuals are born, grow, live, work, and age (WHO, 2012), such as socioeconomic status, 

education level, and the availability of health services (HHS ODPHP, 2010a). Though health inequities are 

directly related to the existence of historical and current discrimination and social injustice, one of the 

most changeable factors is the lack of culturally and linguistically appropriate services.

Health inequities result in disparities that directly affect the quality of life for all individuals. Health 

disparities adversely affect neighborhoods, communities, and the broader society, thus making the issue 

not only an individual concern but also a public health concern. In the United States, it has been 

estimated that the combined cost of health disparities and subsequent deaths due to inadequate and/or 

inequitable care is $1.24 trillion (LaVeist et al., 2009). Culturally and linguistically appropriate services are 

increasingly recognized as effective in improving the quality of care and services (Beach et al., 2004; 

Goode et al., 2006). By providing a structure to implement culturally and linguistically appropriate 

services, the enhanced National CLAS Standards will improve an organization’s ability to address health 

care disparities.

There are numerous ethical and practical reasons why providing culturally and linguistically appropriate 

services in health and health care is necessary. The following reasons have been identified by the 

National Center for Cultural Competence (Cohen & Goode, 1999, revised by Goode & Dunne, 2003):

1. To respond to current and projected demographic changes in the United States.

2. To eliminate long-standing disparities in the health status of people of diverse racial, ethnic 

and cultural backgrounds.

3. To improve the quality of services and primary care outcomes.

4. To meet legislative, regulatory and accreditation mandates.

5. To gain a competitive edge in the market place.

6. To decrease the likelihood of liability/malpractice claims.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

The Case for the Enhanced National CLAS Standards 15

The motivations for implementing CLAS are as varied as the approaches different stakeholders are taking 

toward implementation, and depend upon the stakeholder’s mission, goals, and sphere of influence 

(Betancourt, Green, Carrillo, & Park, 2005). The six reasons for the implementation of cultural 

competency as described by the National Center for Cultural Competence fall into two frequently cited 

overarching philosophies: one that pertains to social justice (e.g., Kumagai & Lypson, 2009; Sue, 2001) 

and the other that pertains to standards of business (Brach & Fraser, 2002). Specifically, reasons number 

one and number two are consistent with the social justice philosophy, which emphasizes diversity and the 

improvement of services to underserved populations. The remaining reasons are consistent with the 

standards of business philosophy, which focuses on strengthening business practices and business 

development.

The enhanced National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic 

Health Disparities (HHS, 2011) and the National Stakeholder Strategy for Achieving Health Equity 

(National Partnership for Action to End Health Disparities, 2011a), which aim to promote health equity 

through providing clear plans and strategies to guide collaborative efforts that address racial and ethnic 

health disparities across the country. Similar to these initiatives, the enhanced National CLAS Standards 

are intended to advance health equity, improve quality, and help eliminate health care disparities by 

providing a blueprint for individuals and health and health care organizations to implement culturally and 

linguistically appropriate services. Adoption of these Standards will help advance better health and health 

care in the United States.

The following sections expound upon the reasons why culturally and linguistically appropriate services in 

health and health care are necessary, as listed by the National Center for Cultural Competence.

Respond to Demographic Changes 

It is projected that by 2050 the U.S. demographic makeup will be 47% non-Hispanic White, 29% 

Hispanic, 13% Black and 9% Asian (Passel & Cohn, 2008). According to the most recent data, 

approximately 20% of the U.S. population, or a little over 58 million people, speak a language other than 

English at home, and of that 20%, almost 9% (over 24 million people) have limited proficiency in English 

(Au, Taylor, & Gold, 2009; U.S. Census Bureau, 2010), which has implications for their proficiency in 

health and health care (The Joint Commission, 2010). Given the increasing cultural diversity over the last 

several decades (e.g., Genao, Bussey-Jones, Brady, Branch, & Corbie-Smith, 2003; Goode et al., 2006) 

and the rapidly changing landscape of health and health care in the United States (Chin, 2000), there is 

an increased need for health and health care professionals and organizations to provide effective, highquality care that is responsive to the diverse cultural and linguistic needs of individuals served.

The need for culturally and linguistically appropriate care is particularly great since similar demographic 

changes have not occurred in the health and health care workforce (e.g., Genao et al., 2003; Institute of 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

The Case for the Enhanced National CLAS Standards 16

Medicine [IOM], 2004; Sullivan & Mittman, 2010). Given the important role that culture plays in health 

and health behaviors (Kleinman, Eisenberg, & Good, 1978; Tseng & Streltzer, 2008), the lack of 

workforce diversity is significant since it widens the cultural gap that already exists between health and 

health care professionals and consumers, which subsequently contributes to the persistence of health 

disparities (Brach & Fraser, 2000; Genao et al., 2003). The provision of culturally and linguistically 

appropriate services can help to bridge this gap.

Eliminate Health Disparities 

The prevalence of health disparities has been well-documented. For example, racial and ethnic minorities 

have disproportionately higher rates of chronic disease and disability, higher mortality rates, and lower 

quality of care, compared to non-Hispanic whites (e.g., Health Research & Educational Trust [HRET], 

2011; IOM, 2003). In addition, even with expanded insurance coverage, racial minorities are less likely to 

receive needed behavioral health services comparable to non-Latino Whites (Alegria, Lin, Chen, Duan, 

Cook, & Meng, 2012). Health disparities exist beyond racial and ethnic groups; for example, individuals 

with lower incomes are more likely to experience preventable hospitalizations compared to individuals 

with higher incomes (HHS Centers for Disease Control and Prevention [CDC], 2011). In addition, lesbian 

women are less likely to receive preventative cancer screenings than their heterosexual counterparts 

(Buchmueller & Carpenter, 2010), and men who have sex with men are less likely to have access to 

health and behavioral health care than the general population of men (e.g., Alvy, McKirnan, DuBois, 

Ritchie, Fingerhut, & Jones, 2011; Buchmueller & Carpenter, 2010; McKirnan, DuBois, Alvy, & Jones, 

2012).

The provision of culturally and linguistically appropriate services is increasingly recognized as a key 

strategy to eliminating disparities in health and health care (e.g., Betancourt, 2004; 2006; Brach & 

Fraser, 2000; HRET, 2011). Among several other factors, lack of cultural competence and sensitivity 

among health and health care professionals has been associated with the perpetuation of health 

disparities (e.g., Geiger, 2001; Johnson, Saha, Arbelaez, Beach, & Cooper, 2004). This is often the result 

of miscommunication and incongruence between the patient or consumer’s cultural and linguistic needs 

and the services the health or health care professional is providing (Zambrana, Molnar, Munoz, & Lopez, 

2004). The provision of culturally and linguistically appropriate services can help address these issues by 

providing health and health care professionals with the knowledge and skills to manage the providerlevel, individual-level, and system-level factors referenced in the Institute of Medicine’s seminal report 

Unequal Treatment that intersect to perpetuate health disparities (IOM, 2003).
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A Blueprint for Advancing and Sustaining CLAS Policy and Practice

The Case for the Enhanced National CLAS Standards 17

Improve Quality of Services and Care 

Health and health care professionals and organizations strive to provide high quality services that meet 

the needs of all the individuals they serve. High quality care and services are those provided respectfully 

and equitably to all populations served (American Medical Association [AMA], 2006; IOM, 2001). A 

commitment to high quality services and care is often reflected in organizations’ mission statements or 

core values.

Culture influences health beliefs and practices, as well as health seeking behavior and attitudes (IOM, 

2003). When health and health care professionals are aware of culture’s influence on health beliefs and 

practices, they can use this awareness to consider and address issues such as access to care. This is just 

one example of how culturally and linguistically appropriate services can help improve health and health 

care quality (Betancourt, 2006). Culturally and linguistically appropriate services are increasingly 

recognized as effective in improving the quality of services (Beach et al., 2004; Goode et al., 2006), 

increasing patient safety (e.g., through preventing miscommunication, facilitating accurate assessment 

and diagnosis), enhancing effectiveness, and underscoring patient-centeredness (e.g., Betancourt, 2006; 

Brach & Fraser, 2000; Thom, Hall, & Pawlson, 2004).

Meet Legislative, Regulatory, and Accreditation Mandates 

Culturally and linguistically appropriate services are increasingly included in or referenced by local and 

national legislative, regulatory, and accreditation mandates. For example, the Patient Protection and 

Affordable Care Act (the Affordable Care Act), Pub. L. No. 111-148 (2010), as amended by the Health 

Care and Education Reconciliation Act of 2012, Pub. L. No. 111-152 (2012), referred to collectively as the

Affordable Care Act, contains several provisions related to culturally and linguistically appropriate 

services. Section 1311(i)(3)(E) of the Affordable Care Act requires that outreach and education efforts by 

Navigators – entities that receive grants from health insurance exchanges created under the Affordable 

Care Act to assist individuals in accessing and taking advantage of the exchanges – be culturally and 

linguistically appropriate. Furthermore, under sections 2715 and 2719 of the Public Health Service Act as 

amended by the Affordable Care Act, insurance companies are required to provide certain disclosures and 

notices in a culturally and linguistically appropriate manner.
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A Blueprint for Advancing and Sustaining CLAS Policy and Practice

The Case for the Enhanced National CLAS Standards 18

Figure 1: State Legislation

In addition, under Title VI of the Civil Rights Act of 1964, as implemented by Executive Order 13166, 

organizations receiving federal funds must take reasonable steps to provide meaningful access to their 

programs for individuals with limited English proficiency (Executive Order no. 13,166, 2000). 

Furthermore, several states have recognized the importance of cultural and linguistic competency by 

legislating cultural and linguistic competency training in health care. These mandates help state health 

agencies incorporate cultural and linguistic competency into the health services they provide. As of 2012, 

six states have moved to mandate some form of cultural and linguistic competency for either all or a 

component of its health care workforce (see Figure 1) (HHS OMH Think Cultural Health, 2012).

Accrediting bodies such as The Joint Commission and the National Committee for Quality Assurance have 

established accreditation standards that target the improvement of communication, cultural competency, 

patient-centered care, and the provision of language assistance services (Briefer French, Schiff, Han, & 

Weinick, 2008; Wilson-Stronks & Galvez, 2007).
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

The Case for the Enhanced National CLAS Standards 19

Gain a Competitive Edge in the Market Place 

Culturally and linguistically appropriate services can also help health and health care professionals and 

organizations gain a competitive edge in the market place. Although the implementation of culturally and 

linguistically appropriate services certainly requires resources, there are numerous business-related 

advantages to investing these resources. By implementing culturally and linguistically appropriate services 

– including the provision of communication and language assistance, as well as partnerships with the 

community – an organization can develop a positive reputation in the service area and therefore expand 

its market share. The provision of effective, equitable, understandable, and respectful quality care and 

services helps cultivate a loyal consumer base, which then solidifies this market share (AMA, 2006).

As the American Medical Association notes, “a loyal consumer base helps organizations avoid costly 

problems, such as high turnover, low utilization rates, and unused capacity” (AMA, 2006, p. 112). In 

addition, culturally and linguistically appropriate services, such as assessments of community health 

assets and needs, help organizations tailor their services, making the services more cost-effective (e.g., 

Hornberger, Itakura, & Wilson, 1997).

Overall, culturally and linguistically competent practices can help organizations gain a competitive edge in 

the market place, as illustrated in the following examples (Alliance of Community Health Plans 

Foundation, 2007):

o Holy Cross Hospital in Maryland increased its market share among individuals with limited 

English proficiency by creating 68 individual maternity suites with a substantial cultural 

competency component in their design. Deliveries at the maternity suites increased from 

7,300 to 9,300 annually.

o Contra Costa Health Services in California implemented a Remote Video/Voice Medical 

Interpretation Project, which increased the overall effectiveness of interpretation services. 

With the addition of this service, the hospital serves twice the number of patients it did 

before the service was available, and for significantly lower costs.

Decrease the Risk of Liability 

The literature illustrates the vital role communication plays in avoiding cases of malpractice due to 

diagnostic and treatment errors (Goode et al., 2006). When communicating with culturally and 

linguistically diverse populations, the opportunity for miscommunication and misunderstanding increases, 

which subsequently increases the likelihood of errors (Youdelman & Perkins, 2005). These errors, in turn, 

can cost millions of dollars in liability or malpractice claims. Culturally and linguistically appropriate

services can reduce the possibility of such errors. For example, a first responder in Florida misinterpreted 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

The Case for the Enhanced National CLAS Standards 20

a single Spanish word, “intoxicado,” to mean "intoxicated" rather than its intended meaning of "feeling 

sick to the stomach." This led to a delay in diagnosis, which resulted in a potentially preventable case of 

quadriplegia, and ultimately, a $71 million malpractice settlement (Flores, 2006).

The HHS Health Resources and Services Administration [HRSA] found that health professionals who lack 

cultural and linguistic competency can be found liable under tort principles in several areas (2005). For 

instance, providers may be presumed negligent if an individual is unable to follow guidelines because 

they conflict with his/her beliefs and the provider neglected to identify and try to accommodate the 

beliefs (HRSA, 2005). Additionally, if a provider proceeds with treatment or an intervention based on 

miscommunication due to poor quality language assistance, he/she and his/her organization may face 

increased civil liability exposure (DeCola, 2010). Thus, culturally and linguistically appropriate 

communication is essential to minimize the likelihood of liability and malpractice claims.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

The Enhanced National CLAS Standards 21

The Enhanced National CLAS Standards

The Standards 

The enhanced National Standards for Culturally and Linguistically Appropriate Services in Health and 

Health Care from the Office of Minority Health at the U.S. Department of Health and Human Services are 

composed of 15 Standards that provide individuals and organizations with a blueprint for successfully 

implementing and maintaining culturally and linguistically appropriate services. Culturally and linguistically 

appropriate health care and services, broadly defined as care and services that are respectful of and 

responsive to the cultural and linguistic needs of all individuals, are increasingly seen as essential to 

reducing disparities and improving health care quality.

All 15 Standards are necessary to advance health equity, improve quality, and help eliminate health care 

disparities. As important as each individual Standard is, the exclusion of any Standard diminishes health 

professionals’ and organizations’ ability to meet an individual’s health and health care needs in a culturally 

and linguistically appropriate manner. Thus, it is strongly recommended that each of the 15 Standards be 

implemented by health and health care organizations.

Purpose 

The purpose of the enhanced National CLAS Standards is to provide a blueprint for health and health care 

organizations to implement culturally and linguistically appropriate services that will advance health 

equity, improve quality, and help eliminate health care disparities.

Audience 

All members of the health and health care community can benefit from the framework offered by the 

enhanced National CLAS Standards. The enhanced National CLAS Standards are directed toward a 

broader audience than the original Standards in order to address more fully every point of contact 

throughout the health care and health services continuum. A wide spectrum of professionals and 

organizations influence health and health care every day. The following is a partial list of audiences of the 

enhanced National CLAS Standards and how each type of audience might utilize them:

o Accreditation and Credentialing Agencies: to assess and compare health care facilities, 

health and human service organizations, and providers who offer culturally and linguistically 

appropriate services and ensure quality for diverse populations. Institutions such as The Joint 

Commission and the National Committee for Quality Assurance have made great strides in 

implementing policies and standards to help ensure these quality services.
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A Blueprint for Advancing and Sustaining CLAS Policy and Practice

The Enhanced National CLAS Standards 22

o Community-Based Organizations: to promote quality health care for diverse populations and 

to assess and monitor care and services being delivered. The potential advocate audience is 

broad and includes: legal services, consumer education agencies, faith-based organizations, and 

other local, regional, or national nonprofit organizations that address health and health care 

issues.

o Educators: to incorporate cultural and linguistic competency into their curricula and to raise 

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

audience would include educators from academic institutions, state health professional licensing 

agencies, and educators from legal and social service professions.

o Governance and Leadership: to draft consistent and comprehensive laws, regulations, and 

contract language. This audience would include federal, state, tribal, and local governments. The 

audience would also include the individuals within organizations who are responsible for 

developing regulations and contracts, as well as the leadership responsible for decision making 

regarding regulations and contracts.

o Health Care and Service Providers: to incorporate cultural and linguistic competency into the 

delivery of quality health care and services. This audience would include clinicians, practitioners, 

and service delivery organizations across health and allied health disciplines, including behavioral 

health.

o Health and Health Care Staff and Administrators: to implement culturally and linguistically 

appropriate services throughout an organization, at every point of contact. This audience would 

include employees, contractors, and volunteers serving throughout the organization.

o Patients/Consumers: to understand their right to receive accessible and appropriate health 

and health care services and to evaluate whether providers can offer them.

o Public Health Workforce: to implement cultural and linguistic competency into the provision of 

public health services. This audience would include those involved in the behavioral health, 

emergency medical services, environmental health, epidemiology, and global health.

o Purchasers: to promote the needs of diverse consumers of health benefits, and leverage 

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

purchasers of health benefits.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

The Enhanced National CLAS Standards 23

Components of the Standards 

The enhanced National CLAS Standards are built upon the groundwork laid by the original Standards 

developed in 2000. The enhanced Standards incorporate broader definitions of culture and health and 

aim to reach a broader audience, in an effort to ensure that every individual has the opportunity to 

receive culturally and linguistically appropriate health care and services.

The enhanced National CLAS Standards are organized into one Principal Standard and three themes: (1) 

Governance, Leadership, and Workforce; (2) Communication and Language Assistance; and (3) 

Engagement, Continuous Quality Improvement, and Accountability. Individuals and organizations may 

identify or utilize additional standards that are relevant to their mission and services and are encouraged 

to add to the National CLAS Standards.

Strategies for Implementation 

Implementation of the National CLAS Standards will vary from organization to organization. Therefore, 

organizations should identify the best implementation methods appropriate to their size, mission, scope, 

and type of services offered. It is also important to develop measures to examine the effectiveness of the 

programs being implemented, identify areas for improvement, and identify next steps. Many of these 

measures and evaluation strategies may already be in place throughout an organization for the purposes 

of accreditation and grant management. Health and human service providers, emergency responders, 

community-based organizations, and health care delivery sites (e.g., hospitals, clinics, and community 

health centers) will have different goals and expectations for the National CLAS Standards. Therefore, 

their strategies for implementation may differ widely.

The enhanced National CLAS Standards and The Blueprint include specific implementation strategies to 

further the establishment or expansion of culturally and linguistically appropriate services. Prior to 

implementation, it is important to have a vision of what culturally and linguistically appropriate services 

would look like within the organization and to identify available and required resources (e.g., structure, 

funding, and personnel) to ensure success.

Responsibilities associated with implementing the enhanced National CLAS Standards should be 

distributed throughout the organization to ensure comprehensive engagement and effectiveness so that 

no single individual or department bears the responsibility for the entire organization. For example, some 

organizations find it helpful to establish an interdisciplinary or cross-departmental committee that will 

help identify, implement, and sustain the elements of a well-developed CLAS plan.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Enhancements to the National CLAS Standards 24

Enhancements to the National CLAS Standards

Data collected during the HHS Office of Minority Health’s National Standards for Culturally and 

Linguistically Appropriate Services in Health and Health Care Enhancement Initiative supported the notion 

that it was time for an enhancement of the original National CLAS Standards. In the beginning stages of 

the Enhancement Initiative, a majority of individuals who provided public comment on the original 

National CLAS Standards indicated that though the Standards met their needs as a whole, additional 

guidance or direction was needed.

More specifically, individuals and organizations who provided public comment sought clarification on the 

Standards’ intention, terminology, and implementation strategies. There was also strong support, from 

public comment, the Advisory Committee, and a literature review, for expanding the concepts of health 

and culture. The enhanced National CLAS Standards and The Blueprint aim to address these issues. The 

format of The Blueprint reflects the suggestions provided during the public comment period.

The past decade has shown that the National CLAS Standards are dynamic in nature. Therefore, as best 

and promising practices develop in the field of cultural and linguistic competency, there will be future 

enhancements of the National CLAS Standards. In addition, the Web version of The Blueprint will be 

updated periodically with additional information and resources as the Standards are disseminated in the 

field and as new information is gathered regarding promising implementation and management 

strategies.

The following sections discuss the enhancements made to the National CLAS Standards.

Culture 

The enhanced National CLAS Standards have adopted an expanded, broader definition of culture. 

Specifically, in the enhanced National CLAS Standards, culture refers to “the integrated pattern of 

thoughts, communications, actions, customs, beliefs, values, and institutions associated, wholly or 

partially, with racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, 

geographical, or sociological characteristics.” This definition is adapted from other widely accepted 

definitions of culture (e.g., Gilbert et al., 2007; HHS OMH, 2005) and attempts to reflect the complex and 

dynamic nature of culture, as well as the numerous ways in which culture has been defined and studied 

across multiple disciplines. Refer to the table below for additional discussion of aspects of culture.

There is considerable recognition that every patient-provider interaction is a cross-cultural interaction and 

that the scope of cultural competency in health care should expand to address multiple markers of 

difference (Khanna, Cheyney, & Engle, 2009; IOM, 2003). The broader definition of culture adopted in 

the enhanced National CLAS Standards mirrors other leading initiatives in the field in terms of scope, 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Enhancements to the National CLAS Standards 25

including Healthy People 2020 from the Department of Health and Human Services (HHS ODPHP, 2010a) 

and The Joint Commission (Advancing Effective Communication, Cultural Competence, and Patient- and 

Family-Centered Care: A Roadmap for Hospitals, 2010). In addition, with the recognition that culture 

includes multiple facets and markers of difference, there is an increased opportunity for health 

professionals to identify and use similarities to improve health and health care interactions.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Enhancements to the National CLAS Standards 26

Individuals do not experience their lives or their health through a single lens of identity (e.g., solely race, 

gender, or religious); rather, many elements inform their perceptions, beliefs, customs, and reactions 

(e.g., Frable, 1997). Figure 2 depicts various aspects of culture through which an individual may 

frequently experience his/her cultural identity. For example, an individual’s religious/spiritual 

characteristics often overlap with and are informed by the sociological and racial/ethnic groups with 

which he/she identifies (e.g., an African American Christian male may experience the world 

simultaneously by his race, sex, and religious beliefs). Each of the circles within Figure 2 represents a 

very broad area of culture, as described within the definition. These areas are by no means exhaustive, 

as there are many other aspects of cultural identity.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Enhancements to the National CLAS Standards 27

(Graves, 2001, revised 2011)

Figure 2: Interrelationship of Aspects of Culture

Health 

Health encompasses many aspects, including physical, mental, social, and spiritual well-being (HHS IHS, 

n.d.; HHS OSG et al., 2012; WHO, 1946). The World Health Organization also notes that health is “not 

merely the absence of disease or infirmity” (WHO, 1946). From this perspective, health status falls along 

a continuum and therefore can range from poor to excellent. In addition, how individuals experience 

health and define their well-being is greatly informed by their cultural identity. The advancement of 

health equity allows the attainment of the highest level of health for all people.

Health and Health Care Organizations 

Adopting a more comprehensive conceptualization of health requires, by extension, a more inclusive 

recognition of the variety of professionals and organizations providing the related care and services. The 

enhanced National CLAS Standards reference both health and health care organizations and professionals 

to acknowledge those working not only in health care delivery facilities (e.g., hospitals, clinics, community 

health centers) but also in organizations that provide services such as behavioral and mental health, 

public health, emergency services, and community health and prevention. The National CLAS Standards 

are intended for use within all areas of health and human services.

This expansion also acknowledges the growing body of literature that pertains to the social determinants 

of health, defined by the World Health Organization as the “the conditions in which people are born, 

grow, live, work, and age, including the health system” and the role that social, economic, and 

environmental factors, such as socio-economic status and housing, play in health outcomes between 

different populations (WHO, 2012). The enhanced National CLAS Standards should be understood as 

applicable to hospitals or other health care delivery organizations as well as any public or private 

institution addressing individual, family, or community health, health care, or well-being.
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A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Enhancements to the National CLAS Standards 28

Individuals and Groups 

To further reflect the more inclusive nature of the enhanced National CLAS Standards, the enhanced 

Standards use the terminology individuals and groups in lieu of patients and consumers. Individuals and 

groups encompass patients, consumers, clients, recipients, families, caregivers, and communities.

Statement of Intent 

In response to public comment and the National Project Advisory Committee feedback requesting further 

clarification on the intent of the National CLAS Standards, a statement of intent for the enhanced National 

CLAS Standards was crafted and has been added as an introductory statement to the Standards.

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

The addition of the intention statement ties the culturally and linguistically competent policies and 

practices posed in the enhanced National CLAS Standards directly to the goals of advancing health equity, 

improving quality, and eliminating health care disparities.

Advance Health Equity

Health equity is defined as the attainment of the highest level of health for all people (HHS OMH, 2011). 

Currently, many individuals are unable to attain their highest level of health for several reasons, including 

social factors such as inequitable access to quality care and individual factors such as limited resources. 

Lack of health equity has a significant economic and societal impact. Recent research on the economic 

burden of health inequality and health disparities found that:

o Approximately 30.6% of direct medical care expenditures for African Americans, Asians, and 

Hispanics were excess costs due to health inequalities (LaVeist et al., 2009).

o Eliminating health inequalities for minorities would have reduced indirect costs associated with 

illness and premature death by more than $1 trillion (LaVeist et al., 2009).

Improve Quality

Culturally and linguistically appropriate services and related education initiatives affect several aspects of 

an organization’s continuous quality improvement initiatives. For example, research suggests that after 

implementation of CLAS initiatives, there are substantial increases in provider knowledge and skill 

acquisition and improvements in provider attitudes toward culturally and linguistically diverse patient 

populations (Beach et al., 2004). Studies also indicate that patient satisfaction increases when culturally 

and linguistically appropriate services are delivered (Beach et al., 2004). At the organizational level, 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Enhancements to the National CLAS Standards 29

hospitals and clinics that support effective communication by addressing CLAS have been shown to have 

higher patient-reported quality of care and more trust in the organization (Wynia, Johnson, McCoy, 

Passmore Griffin, & Osborn, 2010). Preliminary research has shown a positive impact of CLAS on patient 

outcomes (Lie, Lee-Rey, Gomez, Bereknyel, & Braddock, 2010), and a growing body of evidence 

illustrates the effectiveness of culturally and linguistically appropriate services in improving the quality of 

care and services received by individuals (Beach et al., 2004; Goode et al., 2006).

Help Eliminate Health Care Disparities

Eliminating health care disparities is one of the ultimate goals of advancing health equity. Disparities exist 

and persist across many culturally diverse groups, with individuals who identify as racial or ethnic 

minorities being less likely to receive preventive health services, even when insured (DeLaet, Shea, & 

Carrasquillo, 2002).

The following are a few selected findings featured in the HHS Agency for Healthcare Quality and 

Research [AHRQ] 2011 National Healthcare Quality Report and National Healthcare Disparities Report 

that highlight the disparities experienced by many in the United States (AHRQ, 2012a, 2012b):

o Access to quality health care remains suboptimal, particularly for minority and low-income 

groups.

o Despite improvements in quality, access and disparities have not improved.

o Certain services, geographic areas and populations were found to be in serious need of 

improvements in quality and progress in disparities reduction.

As the enhanced National CLAS Standards are disseminated, the inclusion of the statement of intent 

within the actual Standards ensures that every person who uses the Standards will understand their 

importance. Although this brief introductory statement cannot convey all the potential purpose(s) of the 

Standards, it does convey their primary goals.

Clarity and Action 

Each of the National CLAS Standards was revised for greater clarity and focus. In addition, the wording of 

each of the 15 Standards now begins with an action word to emphasize how the desired goal may be 

achieved.

Standards of Equal Importance 

The original National CLAS Standards designated each Standard as a recommendation, mandate, or 

guideline. The recommendation (original Standard 14) was a suggestion for voluntary adoption by health 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Enhancements to the National CLAS Standards 30

care organizations. The mandates (original Standards 4, 5, 6, and 7) were Federal requirements for all 

recipients of Federal funds. The guidelines (original Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13) were 

activities recommended for adoption as mandates by Federal, State, and national accrediting agencies.

However, the enhanced National CLAS Standards promote collective adoption of all Standards as the 

most effective approach to improve the health and well-being of all individuals. The Standards are 

intended to be used together, as mutually reinforcing actions, and each of the 15 Standards should be 

understood as an equally important guideline to advance health equity, improve quality, and help 

eliminate health care disparities.

Although the enhanced National CLAS Standards do not represent statutory requirements, failure by a 

recipient of Federal financial assistance to provide services consistent with Standards 5 through 8 could 

result in a violation of Title VI of the Civil Rights Act of 1964 implementing regulation (See 42 USC 2000d 

et. Seq. and 45 CFR Part 80). Therefore, although Standards 5 through 8 do not represent legal 

requirements in all cases, implementation of these goals will help ensure that health care organizations 

and individual providers serve persons of diverse backgrounds in a culturally and linguistically appropriate 

manner and in accordance with the law. Advances in technology help health and human service 

organizations provide efficient and cost-effective language assistance services (Sperling, 2011). Health 

care organizations and individual providers are encouraged to seek technical assistance from the HHS 

Office for Civil Rights or review the HHS Guidance to Federal Financial Assistance Recipients Regarding 

Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons

document (HHS Office for Civil Rights [OCR], 2003) to assess whether or to what extent language access 

services must be provided in order to comply with the Title VI requirement to take reasonable steps to 

provide meaningful access to their programs for persons with limited English proficiency.

Principal Standard and Three Enhanced Themes 

The enhanced Standards have been reorganized to address feedback gleaned from the Enhancement 

Initiative and to improve their overall intention, clarity, and practicality.

The enhanced National CLAS Standards elevate the previous Standard 1 to the status of a Principal 

Standard, add a governance and leadership Standard as Standard 2, and reframe the three themes.1

 1 A crosswalk of the National CLAS Standards 2000 and 2012 may be found in Appendix D.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Enhancements to the National CLAS Standards 31

Figure 3: Enhanced National CLAS Standards’ Themes

The names of the three themes have been updated both to clarify intent and to broaden the scope of 

their interpretation and application.

Principal Standard

Standard 1 has been made the Principal Standard with the understanding that it frames the essential goal 

of all of the Standards, and if the other 14 Standards are adopted, implemented, and maintained, then 

the Principal Standard will be achieved.

1. Provide effective, equitable, understandable, respectful, and quality care and services that are 

responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, 

and other communication needs.

Theme 1: Governance, Leadership, and Workforce

Changing the name of Theme 1 from Culturally Competent Care to Governance, Leadership, and 

Workforce provides greater clarity on the specific locus of action for each of these Standards and 

emphasizes the importance of the implementation of CLAS as a systemic responsibility, requiring the 

investment, support, and training of all individuals within an organization.

The Standards in this theme include:

2. Advance and sustain governance and leadership that promotes CLAS and health equity

3. Recruit, promote, and support a diverse governance, leadership, and workforce

4. Educate and train governance, leadership, and workforce in CLAS
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Enhancements to the National CLAS Standards 32

Theme 2: Communication and Language Assistance

Changing the name of Theme 2 from Language Access Services to Communication and Language 

Assistance broadens the understanding and application of appropriate services to include all 

communication needs and services, including sign language, braille, oral interpretation, and written 

translation.

The Standards in this theme include:

5. Offer communication and language assistance

6. Inform individuals of the availability of language assistance

7. Ensure the competence of individuals providing language assistance

8. Provide easy-to-understand materials and signage

Theme 3: Engagement, Continuous Improvement, and Accountability

Changing the name of Theme 3 from Organizational Supports to Engagement, Continuous Improvement, 

and Accountability underscores the importance of establishing individual responsibility in ensuring that 

CLAS is supported, while retaining the understanding that effective delivery of CLAS demands actions 

across an organization. This revision focuses on the supports necessary for adoption, implementation, 

and maintenance of culturally and linguistically appropriate policies and services regardless of one’s role 

within an organization or practice. All individuals are accountable for upholding the values and intent of 

the National CLAS Standards.

The Standards in this theme include:

9. Infuse CLAS goals, policies, and management accountability throughout the organization’s 

planning and operations

10. Conduct organizational assessments

11. Collect and maintain demographic data

12. Conduct assessments of community health assets and needs

13. Partner with the community

14. Create conflict and grievance resolution processes

15. Communicate the organization’s progress in implementing and sustaining CLAS
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Enhancements to the National CLAS Standards 33

New Standard: Organizational Governance and Leadership 

Another theme that emerged from the feedback provided during the Enhancement Initiative was the 

importance of CLAS being infused throughout an organization. This requires both a bottom-up and a topdown approach to advancing and sustaining CLAS. Organizational governance and leadership are key to 

ensuring the successful adoption, implementation, and maintenance of CLAS. In recognition of this, the 

enhanced National CLAS Standards include a new Standard focused on the role of governance and 

leadership as it relates to CLAS. This new Standard was placed as the second Standard and within Theme 

1, “Governance, Leadership, and Workforce.”

The new second Standard states:

Advance and sustain organizational governance and leadership that promotes CLAS and health equity 

through policy, practices, and allocated resources.

The inclusion of a Standard for organizational governance and leadership emphasizes the importance of a 

comprehensive effort to infuse culturally and linguistically appropriate services throughout an 

organization. The responsibility to embrace CLAS should fall throughout the entire organization. This 

comprehensive effort cannot succeed unless the governance and leadership of an organization has 

embraced these values and are willing to implement and sustain them. In addition, the scope of 

Standards 3 and 4 (Standards 2 and 3 in the original Standards) were expanded to include “governance 

and leadership” to continue to emphasize their integral role in the successful adoption of CLAS.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Looking Ahead: The Future and the National CLAS Standards 34

Looking Ahead: The Future and the National CLAS Standards

Since the inception of the original National CLAS Standards in 2000, the fields of cultural and linguistic 

competency have proven to be as dynamic as the diversity of our communities and the fields of health 

and health care themselves. Looking ahead, the ultimate goal is to ensure that the National CLAS 

Standards remain relevant until the next Enhancement Initiative. Following are some of the areas 

currently under consideration to achieve this goal.

Continued Enhancements 

In recognition of this dynamic landscape, the HHS Office of Minority Health will revisit The Blueprint

periodically to incorporate new and relevant resources as appropriate. Therefore, a Web version of The 

Blueprint will be maintained, which will reflect the more comprehensive and up-to-date resource.

In the event that a change in national policy occurs or research is published that impacts the integrity or 

validity of any of the Standards or content within the Standard chapters, appropriate revisions will be 

made and noted on the Office of Minority Health’s Think Cultural Health website

(www.thinkculturalhealth.hhs.gov).

State and Federal Legislation 

State Legislation: Mandating Cultural and Linguistic Competency Training

In the years since the launch of the original National CLAS Standards, a number of states have 

implemented legislation pertaining to culturally and linguistically appropriate services (Graves, Like, Kelly, 

& Hohensee, 2007; HHS OMH Think Cultural Health, 2012). For many health professionals and 

organizations, the original National CLAS Standards served as a driver or model for what the legislation 

could include.

Federal Legislation: Affordable Care Act of 2010

The Affordable Care Act of 2010 lays an important foundation for advancing health equity and improving 

the quality of services to diverse communities (Andrulis, Siddiqui, Purtle, & Duchon, 2010; Youdelman, 

2011). There are numerous provisions in the health care law related to cultural and linguistic 

competency, and the enhanced National CLAS Standards serve as a resource, at all levels, in these areas.

Support and Guidance 

A recurring theme throughout the public comment portion of the Enhancement Initiative was the request 

for additional support and guidance in the implementation and maintenance of the National CLAS 

Standards. The Blueprint represents the first component of that support and guidance. While The 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Looking Ahead: The Future and the National CLAS Standards 35

Blueprint provides strategies for implementation, more targeted discipline- or profession-specific 

strategies may be necessary. It is anticipated that as part of the ongoing discussion of these efforts, 

collaborations will be formed with the aim of developing discipline specific support and guidance 

documents. Additional supporting documents will be made available on the Think Cultural Health website

(www.thinkculturalhealth.hhs.gov).
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Bibliography 36

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National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

The Blueprint 43

The Blueprint

The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A 

Blueprint for Advancing and Sustaining CLAS offers a user-friendly format for providing comprehensive —

but by no means exhaustive — information on each Standard.

Each chapter is structured in the following manner:

Table 1: Blueprint Chapter Structure

Standard: Statement of the National CLAS Standard

Purpose: A list of many of the Standard’s purposes to contextualize its intent and 

importance

Components of the 

Standard:

An explanation of the Standard’s elements to provide additional information on 

the concepts presented

Strategies for 

Implementation:

Practical recommendations on implementing each Standard in various 

organizations or settings

Resources:

Seminal documents and other relevant resources related to the Standard to 

assist individuals and organizations in laying the foundation for CLAS

Bibliography: Documents cited within the Standard chapter

The HHS Office of Minority Health will also maintain a Web version of The Blueprint to provide a more 

comprehensive and up-to-date resource. It is our hope that The Blueprint will aid in the adoption of the 

enhanced National CLAS Standards in order to help advance better health and health care in the United 

States.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 1 44

Standard 1: Provide Effective, Equitable, Understandable, and 

Respectful Quality Care and Services

Standard 1 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Provide effective, equitable, understandable, and respectful quality care and services that are responsive 

to diverse cultural health beliefs and practices, preferred languages, health literacy, and other 

communication needs.

Purpose 

The purposes of providing effective, equitable, understandable, and respectful quality care and services 

are:

o To create a safe and welcoming environment at every point of contact that both fosters 

appreciation of the diversity of individuals and provides patient- and family-centered care

o To ensure that all individuals receiving health care and services experience culturally and 

linguistically appropriate encounters

o To meet communication needs so that individuals understand the health care and services they 

are receiving, can participate effectively in their own care, and make informed decisions

o To eliminate discrimination and disparities

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Effective, equitable, understandable, and respectful quality care and services

Effective care and services are those that successfully restore an individual to his/her desired health 

status and help to protect his/her future health. An essential part of ensuring that care and services are 

effective is to ensure that they are culturally and linguistically appropriate (IOM, 2003). All health care 

and services should be culturally and linguistically appropriate, including but not limited to health 

promotion, disease prevention, diagnosis, treatment, supportive care, rehabilitation, palliative end-of-life 

care, mental and behavioral health, emergency care, and wellness interventions. Vital to the provision of 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 1 45

effective health care and services, providers must accurately understand the issue or illness, determine 

the course of treatment or services for that individual, and negotiate the solution or treatment 

successfully with the individual. Cultural and linguistic competency allows providers to navigate the 

cultural and linguistic factors that affect trust, rapport, communication, and adherence (Ngo-Metzger et 

al., 2006).

Equitable care and services must apply to all individuals and groups regardless of their cultural 

identity or identities. The aim of equitable care and services is to reduce the burden of illness, injury, and 

disability and to improve the health and functioning of all people in the United States (IOM, 2001). Equity 

is a key component of quality care (National Quality Forum, 2009). Equitable care and services are 

influenced by a number of factors, including but not limited to race, education, health literacy, age, 

sexual orientation, ethnicity, religion, physical or mental disability, language, gender, gender expression, 

gender identity, income, class, and access to care (California Pan-Ethnic Health Network, 2010; National 

Partnership for Action to End Health Disparities, 2011). The Joint Commission states in Advancing 

Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for 

Hospitals that all individuals have the right to be free of discrimination while accessing care or services, 

whether or not that is included in the specific state’s laws and regulations (The Joint Commission, 2010).

Understandable care and services rely on a clear exchange of information between those providing 

care and services and those receiving them. Individuals should be able to fully comprehend how to 

access care and services, what their treatment options are, and what they need to get and stay well. 

Ensuring that care and services are understandable is particularly important to those who have limited 

English proficiency, are deaf or hard of hearing, or may have difficulty comprehending the health care 

system and its terminology. It is estimated that nearly 90% of adults have difficulty using everyday 

health information routinely found in health care facilities, retail outlets, media, and communities. Such 

estimates highlight the significance of ensuring that health care and services are understandable since 

limited health literacy is associated with, among other factors, poorer health outcomes and higher health 

care costs (HHS ODPHP, 2012). See also Health Literacy section of this chapter.

Respectful care and services are important to fostering an environment in which individuals from 

diverse backgrounds will feel comfortable discussing their needs with any member of an organization’s 

staff. The HHS Consumer Bill of Rights states that all recipients of services have “the right to considerate, 

respectful care from all members of the health care system at all times and under all circumstances” 

(Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1997, Chapter 5, 

para. 1).

Accordingly, all members of the health and health care team should:

o Provide individuals with assurances that disrespect or discrimination of any kind is intolerable
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 1 46

o Provide individuals with reasonable assistance to overcome language, cultural, physical, or 

communication barriers

Cultural Health Beliefs and Practices

The integrated pattern of thoughts, communications, actions, beliefs, values, and institutions associated 

with one’s cultural identity informs how individuals perceive illness, its cause, its treatment, and what 

wellness may look like (Horky et al., n.d.). Cultural beliefs and practices also influence how individuals 

cope with chronic or terminal illnesses. Health professionals should understand and be aware of the role 

that cultural health beliefs and practices play in their own lives as well as the lives of the individuals 

seeking services.

A commitment to lifelong learning is an intrinsic value to many in the fields of health and health care 

(Association of American Medical Colleges and American Association of the Colleges of Nursing, 2010; 

American Physical Therapy Association, 2012; American Public Health Association, n.d.). It is incumbent 

upon providers and staff members to include in their lifelong learning an ongoing commitment to selfreflection and honest self-assessment in order to understand how their own cultural beliefs inform their 

daily lives and professional activities (Tervalon & Murray-Garcia, 1998). It is through continued selfassessment and awareness of others’ cultural beliefs that mutually beneficial relationships between 

provider and individual, and between organization and community, may be cultivated.

Providers and staff should inquire about and understand the healing practices and health regimens, 

including traditional healer services, used by the individuals they serve and integrate these approaches 

into treatment plans when appropriate. In the pursuit to learn about the various cultural beliefs and 

health practices in their communities, providers and staff should, whenever possible, gather this 

information directly from the individual seeking care or services. Through this awareness, the provider 

will be able to negotiate treatment options in a culturally and linguistically appropriate manner (American 

Institutes for Research, 2002). As providers and staff learn about the cultural health beliefs and practices 

of different communities, it is important that this knowledge not be used to stereotype or overgeneralize 

(Tervalon & Murray-Garcia, 1998).

Preferred Languages

In the United States, over 24 million people (8.7% of the population) speak English less than very well 

(U.S. Census Bureau, 2010) and should be considered limited English proficient for health and health care 

purposes, according to The Joint Commission’s Advancing Effective Communication, Cultural 

Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (2010). In addition, 

individuals who are conversant in English may not adequately comprehend the complexities of health and 

medical discussions in English. Health professionals should determine the communication and language 

assistance needed for individuals with limited English proficiency, including interpreters, translated 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 1 47

materials, signage and wayfinding. Furthermore, communication should reflect an appropriate health 

literacy level. According to the Roadmap for Hospitals, it is also critical to remember that someone who 

speaks English may not be able to read it (The Joint Commission, 2010). See also Understandable Care 

and Services and Health Literacy sections of this chapter.

Health Literacy

Health literacy is the degree to which an individual has the capacity to obtain, process, and understand 

basic health information and services needed to make appropriate health decisions (HHS ODPHP, 2000).

The majority of American adults have limited ability to be active participants and decision-makers when it 

comes to their health and health care needs.

o Only 12% of adults have proficient health literacy, meaning nearly 9 out of 10 adults may lack 

the skills needed to manage their health and prevent disease (Kutner, Greenburg, Jun, & 

Paulsen, 2006).

o Adults with limited literacy skills are less likely to manage their chronic diseases and more likely 

to be hospitalized than adults with stronger literacy skills. This leads to poorer health outcomes 

and higher health care costs (Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011).

o There is a mismatch between the communication needs of the public and the communication 

level of professionals in the fields of health and human services. The complexity of health 

information and the health care delivery system affect an individual’s ability to understand and 

use health information. A better match between the health literacy level of the population served 

and the health literacy level of the information communicated results in improved 

communication, greater adherence to treatment, greater ability to engage in self-care, improved 

health status, and greater efficiency and cost savings to the health system as a whole (HHS 

ODPHP, 2010).

The HHS Agency for Healthcare Research and Quality has developed a toolkit that outlines health literacy 

universal precautions, defined as “actions that minimize risk for everyone when it is unclear which 

patients may be affected” by low health literacy. Universal precautions are necessary because health 

professionals cannot always identify individuals with low health literacy (AHRQ, 2010) (see Standard 8).

Communication Needs

Individuals frequently report that health professionals are not meeting their communication needs. Racial 

and ethnic minorities, individuals with limited English proficiency, and those with less education are more 

likely to have communication difficulties and to rate health care communication poorly (Wynia & 

Matiasek, 2006). Communication needs of some individuals may be easily recognized, while others may 

be more difficult to discern (Wynia & Matiasek, 2006). According to The Joint Commission’s Advancing 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 1 48

Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for 

Hospitals, organizations should provide communication and language assistance to include interpreters, 

translated materials, signage and wayfinding, augmentative and alternative communication resources, 

and auxiliary aids and services (The Joint Commission, 2010). See Standards 5, 6, 7, and 8 and the 

Glossary for additional information and guidance.

Strategies for Achievement of the Principal Standard 

Standard 1 is the Principal Standard because, conceptually, the ultimate aim in adopting the remaining 

Standards is to achieve Standard 1. Standards 2 through 15 represent the practices and policies intended 

to be the fundamental building blocks of culturally and linguistically appropriate services that are 

necessary to achieve the Principal Standard. For this reason, Strategies for Implementation specific to 

Standard 1 are not listed here. If each of Standards 2 through 15 is implemented and maintained, 

organizations will be better positioned to achieve the desired goal of “effective, equitable, 

understandable, and respectful quality care and services that are responsive to diverse cultural health 

beliefs and practices, preferred languages, health literacy, and other communication needs.”

Resources 

American Medical Association. (2006). Improving communication, improving care: How health care 

organizations can ensure effective, patient-centered communication with people from diverse 

populations. Retrieved from http://www.ama-assn.org/resources/doc/ethics/pcc-consensusreport.pdf

Health Research & Educational Trust, Institute for Diversity in Health Management (2011). Building a 

culturally competent organization: The quest for equity in health care. Retrieved from 

http://www.hret.org/quality/projects/resources/cultural-competency.pdf

National Patient Safety Foundation. (n.d.). Ask me 3. Retrieved from http://www.npsf.org/for-healthcareprofessionals/programs/ask-me-3

Pfizer. (2011). Prevalence calculator. Retrieved from http://www.pfizerhealthliteracy.com/physiciansproviders/PrevalenceCalculator.aspx

Saha, S., Beach, M. C., & Cooper, L. A. (2008). Patient centeredness, cultural competence and healthcare 

quality. Journal of the National Medical Association, 100(11), 1275–1285. Retrieved from 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824588

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2010). 

Health literacy universal precautions toolkit (AHRQ Publication No. 10-0046-EF). Retrieved from 

http://www.ahrq.gov/qual/literacy/
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 1 49

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 

(2010). National action plan to improve health literacy. Retrieved from 

http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf

Wynia, M., & Matiasek, J. (2006). Promising practices for patient-centered communication with vulnerable 

populations: Examples from eight hospitals (Commonwealth Fund Publication No. 947). Retrieved 

from The Commonwealth Fund website: 

http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2006/Aug/Promi

sing%20Practices%20for%20Patient%20Centered%20Communication%20with%20Vulnerable%

20Populations%20%20Examples%20from%20Ei/Wynia_promisingpracticespatientcentered_947

%20pdf.pdf

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

Advisory Commission on Consumer Protection and Quality in the Health Care Industry. (1997). Consumer 

bill of rights and responsibilities: Report to the president of the United States. Retrieved from 

http://www.opm.gov/insure/archive/health/cbrr.htm

Association of American Medical Colleges and American Association of the Colleges of Nursing. (2010). 

Lifelong learning in medicine and nursing: Final conference report. Retrieved from 

https://www.aamc.org/download/121492/data/macyreport2010.pdf.pdf

American Institutes for Research. (2002). Teaching cultural competence in health care: A review of 

current concepts, policies and practices. Retrieved from Office of Minority Health website: 

http://minorityhealth.hhs.gov/assets/pdf/checked/1/em01garcia1.pdf

American Physical Therapy Association. (2012). Professional development, lifelong learning, and 

continuing competence in physical therapy. Retrieved from 

http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Professional_Development/

ProfessionalDev.pdf

American Public Health Association. (n.d.). The education board. Retrieved from 

http://www.apha.org/about/gov/edboard/

Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy 

and health outcomes: An updated systematic review. Annals of Internal Medicine, 155(2), 97–

107.

California Pan-Ethnic Health Network. (2010). Building quality & equitable health care systems.

(Conference report). Retrieved from 

http://www.cpehn.org/pdfs/Building%20Quality%20and%20Equitable%20Health%20Care%20Sy

stems%2010-10.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 1 50

Horky, S., Tribby, R., Becker, C., Phipps, M. J., Saperstein, M., Johnston, J., & Polanco, B.-P. (n.d.). Core 

concepts in cultural competence: Health beliefs. In Cross-cultural health care: Case studies. 

Retrieved from http://support.mchtraining.net/national_ccce/case0/concepts.html#4

Institute of Medicine. (2001). Crossing the quality chasm: A new system of health for the 21st century. 

Retrieved from http://www.nap.edu/openbook.php?isbn=0309072808

Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care.

Retrieved from http://www.nap.edu/openbook.php?record_id=10260&page=R1

The Joint Commission. (2010). Advancing effective communication, cultural competence, and patientand family-centered care: A roadmap for hospitals. Retrieved from 

http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America’s adults: Results 

from the 2003 National Assessment of Adult Literacy (NCES 2006–483). Washington, DC: 

National Center for Education Statistics.

National Partnership for Action to End Health Disparities. (2011). National stakeholder strategy for 

achieving health equity: Development of the national stakeholder strategy. Retrieved from U.S. 

Department of Health and Human Services, Office of Minority Health website: 

http://minorityhealth.hhs.gov/npa/files/Plans/NSS/NSS_05_Section1.pdf

National Quality Forum. (2009). A comprehensive framework and preferred practices for measuring and 

reporting cultural competency: A consensus report. Retrieved from 

http://www.qualityforum.org/Publications/2009/04/A_Comprehensive_Framework_and_Preferred

_Practices_for_Measuring_and_Reporting_Cultural_Competency.aspx

Ngo-Metzger, Q., Telfair, J., Sorkin, D. H., Weidmer, B., Weech-Maldonado, R., Hurtado, M., & Hays, R. 

D. (2006). Cultural competency and quality of care: Obtaining the patient’s perspective. Retrieved 

from The Commonwealth Fund website: http://www.commonwealthfund.org/usr_doc/NgoMetzger_cultcompqualitycareobtainpatientperspect_963.pdf

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical 

distinction in defining physician training outcomes in multicultural education. Journal of Health 

Care for the Poor and Underserved, 9(2), 117–125.

U.S. Department of Commerce, Census Bureau. (2010). American community survey. Retrieved from 

http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_10_3YR

_DP02&prodType=table

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2010). 

Health literacy universal precautions toolkit (AHRQ Publication No. 10-0046-EF). Retrieved from 

http://www.ahrq.gov/qual/literacy/ 

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 

(2000). Health communication and health IT. In Healthy people 2010. Retrieved from 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 1 51

http://www.healthypeople.gov/2010/hp2020/Objectives/TopicArea.aspx?id=25&TopicArea=Healt

h+Communication+and+Health+IT

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 

(2010). National action plan to improve health literacy. Retrieved from 

http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 

(2012). Health literacy. Retrieved from http://www.health.gov/communication/literacy

Wynia, M., & Matiasek, J. (2006). Promising practices for patient-centered communication with vulnerable 

populations: Examples from eight hospitals (Commonwealth Fund Publication No. 947). Retrieved 

from The Commonwealth Fund website: 

http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2006/Aug/Promi

sing%20Practices%20for%20Patient%20Centered%20Communication%20with%20Vulnerable%

20Populations%20%20Examples%20from%20Ei/Wynia_promisingpracticespatientcentered_947

%20pdf.pdf
National Standards for CLAS in Health and Health Care:

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Standard 2 52

Standard 2: Advance and Sustain Governance and Leadership that 

Promotes CLAS and Health Equity

Standard 2 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Advance and sustain organizational governance and leadership that promotes CLAS and health equity 

through policy, practices, and allocated resources.

Purpose 

The purposes of advancing and sustaining governance and leadership that promotes CLAS and health 

equity are:

o To ensure the provision of appropriate resources and accountability needed to support and 

sustain initiatives

o To model an appreciation and respect for diversity, inclusiveness, and all beliefs and practices

o To support a model of transparency and communication between the service setting and the 

populations that it serves

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Advance and sustain organizational governance and leadership that promotes CLAS and 

health equity

Standard 2 is a new Standard that resulted from the National CLAS Standards Enhancement Initiative. 

Standard 2 has been added to underscore that CLAS must permeate every aspect of the organization, 

from the top down and from the bottom up. Cultural and linguistic competency has historically been a 

grassroots strategy. However, it is the organization’s leadership that establishes the culture of the 

organization through its priorities, expectations, and the behavior that it models (Schyve & The 

Governance Institute, 2009) and through designing service delivery processes and expectations (Rice, 

2007).
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 2 53

Health and health care governance and leadership bodies should make their commitment to CLAS highly 

visible to both staff and individuals in their service area (Wilson-Stronks & Galvez, 2007). Leadership, in 

large part, determines whether the organization’s culture will embody quality, safety, and CLAS (Schyve 

& The Governance Institute, 2009), so much so that diversity in leadership has been found to be the 

single most significant predictor of adoption and adherence to the National CLAS Standards (WeechMaldonado, 2007). This may be because support from governance and leadership enables the allocation 

of resources and services necessary to effectively and efficiently meet individual or group communication, 

cultural, religious, spiritual, mobility, and other needs, according to The Joint Commission’s Advancing 

Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for 

Hospitals (2010).

The Health Research and Educational Trust, an affiliate of the American Hospital Association, poses two 

key questions for organizational leadership in regard to prioritizing cultural competency (HRET, 2011):

1. Has your board set goals on improving organizational diversity, providing culturally competent 

care, and eliminating disparities in care as part of your strategic plan?

2. Is diversity awareness and cultural competency training mandatory for all senior leadership, 

management, staff, and volunteers?

These two questions are directly related to enhanced National CLAS Standards 8 and 3, respectively, and 

emphasize that the key strategy for embedding CLAS within an organization is engaging leadership. 

Indeed, research has shown leadership commitment as one of the most significant elements for 

integrating cultural and linguistic competency and moving CLAS from theory to action (HHS OMH, 2004; 

Weech-Maldonado, 2007; Wu & Martinez, 2006). A multi-stakeholder expert panel convened by the 

American Medical Association and Health Research and Educational Trust in 2006 called on all health care 

organizations to regularly assess “leadership involvement; mission, goals and strategies; policies and 

programs; budget allocations; and workforce values” as they relate to culturally and linguistically 

appropriate services (AMA, 2006, pp. 28–32). In one study, patients at hospitals and clinics that scored 

just 5 points higher (out of 100) on a domain measuring resource allocation and leadership engagement 

in addressing CLAS were more likely to report receiving high-quality care and more likely to report high 

levels of trust in the organization, compared to those who scored lower (Wynia et al., 2010). 

Furthermore, the National Quality Forum identifies leadership as one of the seven primary domains for 

measuring and reporting cultural competency.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 2 54

“Leadership recognizes that healthcare providers, clinical and organizational leaders, the governance 

board, and the community share responsibility for and play an essential role in the development and 

implementation of cultural competency activities, in setting policy and strategy and in monitoring 

organization performance. Leadership must aspire to reflect the diversity of the community served.” 

(National Quality Forum, 2009, p. iv)

Promote CLAS and health equity through policy, practices, and allocated resources

Organizational governance and leadership play a key role in promoting CLAS and health equity through 

policies, practices, and resource allocation. Institutionalizing cultural competency into organizations’ 

central missions; collecting race, ethnicity, and primary language data; and increasing the diversity of the 

leadership, governance, and workforce within the organization represent methods that leaders should use 

to improve equity, quality, and efficacy of services (HRET, 2011). The following table illustrates how a 

few prominent health and health care organizations promote CLAS and health equity; namely, through 

policies and practices described in their mission, vision, and/or values statements. While certainly not 

exhaustive, the examples listed illustrate how several organizations have sought to address these topics.

Table 2: Examples of Promoting CLAS Through Policy and Practice

Association URL Mission/Vision/Core Values

American Public 

Health Association

http://www.apha.org/a

bout/gov/execboard/ex

ecutiveboardvisionmissi

on.htm

Mission: Improve the health of the public and achieve equity in 

health status

Johns Hopkins 

Medicine

http://www.hopkinsme

dicine.org/about/missio

n.html

Mission: The mission of Johns Hopkins Medicine is to improve 

the health of the community and the world by setting the 

standard of excellence in medical education, research, and 

clinical care. Diverse and inclusive, Johns Hopkins Medicine 

educates medical students, scientists, health care professionals, 

and the public; conducts biomedical research; and provides 

patient-centered medicine to prevent, diagnose, and treat human 

illness.

Vision: Johns Hopkins Medicine provides a diverse and inclusive 

environment that fosters intellectual discovery, creates and 

transmits innovative knowledge, improves human health, and 

provides medical leadership to the world.

Core Values: Excellence and Discovery, Leadership and 

Integrity, Diversity and Inclusion, Respect and Collegiality

Harvard Medical 

School

http://hms.harvard.edu

/hms/facts.asp

Mission: To create and nurture a diverse community of the best 

people committed to leadership in alleviating human suffering 

caused by disease.
National Standards for CLAS in Health and Health Care:

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Standard 2 55

Association URL Mission/Vision/Core Values

Mayo Clinic

http://www.mayoclinic.

org/about/missionvalue

s.html

Mission: To inspire hope and contribute to health and wellbeing by providing the best care to every patient through 

integrated clinical practice, education, and research.

Values: These values, which guide Mayo Clinic's mission to this 

day, are an expression of the vision and intent of our founders, 

the original Mayo physicians, and the Sisters of Saint Francis.

o Respect: Treat everyone in our diverse community, 

including patients, their families, and colleagues, with 

dignity.

o Compassion: Provide the best care, treating patients and 

family members with sensitivity and empathy.

o Integrity: Adhere to the highest standards of 

professionalism, ethics, and personal responsibility, worthy 

of the trust our patients place in us.

o Healing: Inspire hope and nurture the well-being of the 

whole person, respecting physical, emotional, and spiritual 

needs.

o Teamwork: Value the contributions of all, blending the 

skills of individual staff members in unsurpassed 

collaboration.

o Excellence: Deliver the best outcomes and highest quality 

service through the dedicated effort of every team 

member.

o Innovation: Infuse and energize the organization, 

enhancing the lives of those we serve, through the creative 

ideas and unique talents of each employee.

o Stewardship: Sustain and reinvest in our mission and 

extended communities by wisely managing our human, 

natural, and material resources.

Society of Public 

Health Educators

http://www.sophe.org/

mission.cfm

Values: The Society of Public Health Educators is committed 

to:

o Responding to the needs of its members 

o Delivering quality products and services 

o Demonstrating integrity, accountability and transparency 

o Promoting teamwork and collaboration 

o Embracing diversity 

o Respecting organizational tradition while encouraging 

innovation
National Standards for CLAS in Health and Health Care:

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Standard 2 56

In addition, Johns Hopkins Medicine recently adopted a multiyear strategic plan, entitled Diversity & 

Inclusion 2020, which establishes key goals for patient care, community engagement and involvement, 

and workforce development. In implementing this strategic plan, the organization established an Office of 

Diversity and Cultural Competence and appointed an Associate Dean of Diversity and a diversity 

specialist, and to develop e-learning courses on diversity and cultural competency issues in conjunction 

with the School of Public Health’s Center for Health Disparities Solutions. The hospital has developed 

partnerships with the community to foster increased diversity and community engagement (Johns 

Hopkins Medicine, n.d.).

Strategies for Implementation 

The following are possible implementation strategies for advancing and sustaining governance and 

leadership that promotes CLAS and health equity:

From the National Quality Forum (2009):

o Create and sustain an environment of cultural competency through establishing leadership 

structures and systems or embedding them into existing structures and systems.

o Identify and develop informed and committed champions of cultural competency throughout the 

organization in order to focus efforts around providing culturally competent care.

o Ensure that a commitment to culturally competent care is reflected in the vision, goals, and 

mission of the organization and couple this with an actionable plan.

o Implement strategies to recruit, retain, and promote at all levels of the organization a diverse 

leadership that reflects the demographic characteristics of the populations in the service area.

o Ensure that the necessary fiscal and human resources, tools, skills, and knowledge to support 

and improve culturally competent policies and practices in the organization are available.

o Commit to cultural competency through system-wide approaches that are articulated through 

written policies, practices, procedures, and programs.

o Actively seek strategies to improve the knowledge and skills that are needed to address cultural 

competency in the organization.

From The Joint Commission (Wilson-Stronks & Galvez, 2007):

o Provide for internal multidisciplinary dialogues about language and culture issues.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 2 57

o Create financial incentives to promote, develop, and maintain accessibility to qualified health care 

interpreters.

Resources 

American Medical Association. (2006). Content area 1. Understand your organization’s commitment. In 

Improving communication, improving care: How health care organizations can ensure effective, 

patient-centered communication with people from diverse populations (pp. 28–32). Retrieved 

from http://www.ama-assn.org/resources/doc/ethics/pcc-consensus-report.pdf

Betancourt, J., Green, A., & King, R. (2008). Improving quality and achieving equity: A guide for hospital 

leaders. Retrieved from Massachusetts General Hospital, The Disparities Solutions Center 

website: 

http://www2.massgeneral.org/disparitiessolutions/z_files/disparities%20leadership%20guide_fina

l.pdf

Georgetown University Child Development Center, Center for Child Health and Mental Health Policy, 

National Center for Cultural Competence. (2000). A planner's guide: Infusing principles, content 

and themes related to cultural and linguistic competence into meetings and conferences. 

Retrieved from http://gucchd.georgetown.edu/products/PlannersGuide.pdf

Institute for Diversity in Health Management. (2004). Strategies for leadership: Does your hospital reflect 

the community it serves? Diversity and cultural proficiency assessment tool for leaders. Retrieved 

from http://www.aha.org/content/00-10/diversitytool.pdf

Institute for Diversity in Health Management. (2008). Institute Resource Center. Retrieved from 

http://www.diversityconnection.org/diversityconnection/membership/Institute-ResourceCenter.jsp?fll=S12

Liteman, M., Campbell, S., & Liteman, J. (2006). Retreats that work: Everything you need to know about

planning and leading great offsites. San Francisco, CA: Pfeiffer.

Management Sciences for Health. (n.d.). The provider’s guide to quality & culture. Retrieved from 

http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=English

Powell, L., & Taylor, C. (2004). Hospital governing board assessment: A self-help guide. Boise, ID: 

Mountain States Group.

Schyve, P. M., & The Governance Institute. (2009). Leadership in healthcare organizations: A guide to 

Joint Commission leadership standards. Retrieved from 

http://www.jointcommission.org/assets/1/18/WP_Leadership_Standards.pdf

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 2 58

Bibliography 

American Medical Association. (2006). Content area 1. Understand your organization’s commitment. In 

Improving communication, improving care: How health care organizations can ensure effective, 

patient-centered communication with people from diverse populations (pp. 28–32). Retrieved 

from http://www.ama-assn.org/resources/doc/ethics/pcc-consensus-report.pdf

Health Research & Educational Trust, Institute for Diversity in Health Management (2011). Building a 

culturally competent organization: The quest for equity in health care. Retrieved from 

http://www.hret.org/quality/projects/resources/cultural-competency.pdf

Johns Hopkins Medicine. (n.d.). Diversity & inclusion 2020. Retrieved from 

http://www.hopkinsmedicine.org/bin/s/x/diversity_and_inclusion.pdf

The Joint Commission. (2010). Advancing effective communication, cultural competence, and patientand family-centered care: A roadmap for hospitals. Retrieved from 

http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

National Quality Forum. (2009). A comprehensive framework and preferred practices for measuring and 

reporting cultural competency: A consensus report. Retrieved from 

http://www.qualityforum.org/Publications/2009/04/A_Comprehensive_Framework_and_Preferred

_Practices_for_Measuring_and_Reporting_Cultural_Competency.aspx

Rice, M. F. (2007). Promoting cultural competency in public administration and public service delivery: 

Utilizing self-assessment tools and performance measures. Journal of Public Affairs Education, 13, 

41–57.

Schyve, P. M., & The Governance Institute. (2009). Leadership in healthcare organizations: A guide to 

Joint Commission leadership standards. Retrieved from 

http://www.jointcommission.org/assets/1/18/WP_Leadership_Standards.pdf

U.S. Department of Health and Human Services, Office of Minority Health. (2004). CLAS in health care: 

Implementation of the National Standards for Culturally and Linguistically Appropriate Services in 

Health Care at the Alameda Alliance for Health. Retrieved from 

http://minorityhealth.hhs.gov/assets/pdf/checked/CLAS_healthcare.pdf

Weech-Maldonado, R. (2007, June). Moving towards culturally competent health systems: Organizational 

and market factors. Presented at the AcademyHealth Disparities Interest Group Meeting,

Orlando, FL. Retrieved from 

http://www.academyhealth.org/files/interestgroups/disparities/weech-maldonador.pdf

Wilson-Stronks, A., & Galvez, E. (2007). Hospitals, language, and culture: A snapshot of the nation.

Retrieved from The Joint Commission website: 

http://www.jointcommission.org/assets/1/6/hlc_paper.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 2 59

Wu, E., & Martinez, M. (2006). Taking cultural competency from theory to action (Commonwealth Fund 

Publication No. 964). Retrieved from The Commonwealth Fund website: 

http://www.commonwealthfund.org/usr_doc/Wu_takingcultcomptheoryaction_964.pdf

Wynia, M. K., Johnson, M., McCoy, T. P., Passmore Griffin, L., & Osborn, C. Y. (2010). Validation of an 

organizational communication climate assessment toolkit. American Journal of Medical Quality, 

25(6), 436–443. doi:10.1177/1062860610368428
National Standards for CLAS in Health and Health Care:

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Standard 3 60

Standard 3: Recruit, Promote, and Support a Diverse Governance, 

Leadership, and Workforce

Standard 3 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and 

workforce that are responsive to the population in the service area.

Purpose 

The purposes of recruiting, promoting, and supporting a diverse governance, leadership, and workforce 

are:

o To create an environment in which culturally diverse individuals feel welcomed and valued

o To promote trust and engagement with the communities and populations served

o To infuse multicultural perspectives into planning, design, and implementation of CLAS

o To ensure diverse viewpoints are represented in governance decisions

o To increase knowledge and experience related to culture and language among staff

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Recruit, promote, and support a culturally and linguistically diverse governance, leadership, 

and workforce

It is essential that organizations develop focused strategies to recruit, promote, and support a culturally 

and linguistically diverse governance, leadership, and workforce. Evidence suggests that organizations 

with a more diverse and better-trained workforce provide higher-quality care and experience greater 

patient satisfaction scores (The Sullivan Commission on Diversity in the Healthcare Workforce, 2004; 

IOM, 2003). For example, in one study, organizations scoring higher on a scale of workforce diversity and 

training had better odds of patients reporting that they received high-quality care (Wynia et al., 2010).
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Diversity should be present throughout every level of the organization, from front office personnel to the 

senior leadership. Organizations and their staff should understand that diversity in governance, 

leadership, and the workforce is about ensuring that individuals holding any organizational position 

possess the necessary skills and qualifications to perform required duties. In addition, it should be 

recognized that simply hiring and retaining a culturally diverse governance, leadership, and workforce is 

not, by itself, sufficient to achieving culturally and linguistically appropriate services; all members of the 

organization must be appropriately trained and versed in basic cultural competency skills (Rose, 2011; 

Whealin & Ruzek, 2008). Supporting cultural diversity via recruitment, retention, and promotion is but 

one method to ensure, among other things, that the opportunity for provider-patient concordance exists 

and that the organizational culture is informed from a variety of perspectives (Smedley & Mittman, 2011).

Governance, leadership, and workforce that are responsive to the population in the service

area

The United States is rapidly becoming a more diverse nation. Since the 2000 U.S. Census, the percentage 

of individuals identifying as either Hispanic or Asian has increased substantially (U.S. Census Bureau, 

2011). It is projected that by 2050 the U.S. demographic makeup will be 47% White, 29% Hispanic, 13% 

Black and 9% Asian (Passel & Cohn, 2008). This diversity, however, is not represented within many of 

the health professions. Evidence indicates that an increase in racial and ethnic diversity among health 

professionals is associated with increased access to care for racial and ethnic minority patients, greater 

patient choice, more patient satisfaction and patient engagement, improved communication, and 

improved educational experiences for health students (Cooper & Powe, 2004; IOM, 2004). Being 

responsive to the community is important at all levels of the organization, including in the provision of 

care and services, strategic planning, evaluation, and decision-making (Cooper & Powe, 2004).

Diversity among staff providing direct services in support, outreach, or clinical roles is important but not 

sufficient. Though there may be a lack of diversity within certain health professions, organizations should 

still strive to increase diversity throughout the entire hierarchy of an organization, including among senior 

management, chief executives, and boards of directors. This can promote strategic planning as well as 

policymaking and decision-making that are inclusive of the cultural and linguistic needs of all individuals 

(HHS Health Resources and Services Administration, 2006). Governance, leadership, and a workforce that 

is representative of the diversity of the communities served are motivating forces to make the 

organization’s services increasingly relevant and effective for its constituents (U.S. Department of 

Commerce, 1999).

Responsive care should also apply across various contractual relationships. Many health care 

organizations use networks or affiliated providers to deliver services to their constituents. It is important 

that staff diversity encompasses all individuals involved in health care delivery, whatever their contractual 

or subcontractual relationship with the organization.
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Strategies for Implementation 

The following are possible implementation strategies for the recruitment, promotion, and support of a 

diverse governance, leadership, and workforce:

Recruitment

o Advertise job opportunities in targeted foreign language and minority health professional 

associations’ job boards, publications, and other media (e.g., social media networks, professional 

organizations’ email Listservs, etc.), and post information in multiple languages (QSource, 2005).

o Develop relationships with local schools, training programs, and faith-based organizations to 

expand recruitment base (QSource, 2005).

o Recruit at minority health fairs (QSource, 2005).

o Collaborate with businesses, public school systems, and other stakeholders to build potential 

workforce capacities and recruit diverse staff. In particular, linkages between academic and 

service settings can help identify potential recruits already in the educational “pipeline” and 

provide them with additional academic support and resources necessary to meet job 

requirements (The Sullivan Commission on Diversity in the Healthcare Workforce, 2004).

o Assess the language and communication proficiency of staff to determine fluency and 

appropriateness for serving as interpreters.

Promotion and Support

The Joint Commission’s Advancing Effective Communication, Cultural Competence, and Patient- and 

Family-Centered Care: A Roadmap for Hospitals (2010) provides the following implementation strategies 

for the promotion and support of a diverse governance, leadership, and workforce:

o Create a work environment that respects and accommodates the cultural diversity of the local 

workforce.

o Develop, maintain, and promote continuing education and career development opportunities so 

all staff members may progress within the organization.

o Cultivate relationships with organizations and institutions that offer health and human service

career training to establish volunteer, work-study, and internship programs.

Other strategies for promoting and supporting a diverse governance, leadership, and workforce include

(HHS OMH, 2001):
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o Promote mentoring opportunities.

o Conduct regular, explicit assessments of hiring and retention data, current workforce 

demographics, promotion demographics, and community demographics.

o Monitor work assignments and hire sufficient personnel to ensure a manageable and appropriate 

workload for bilingual/bicultural staff members.

o Use nonclinical support staff in cultural broker positions only after providing sufficient training

and recognition (e.g., compensation, job title, or description).

o Promote diverse staff members into administrative or managerial positions where their cultural 

and linguistic capabilities can make unique contributions to planning, policy, and decision-making.

o Foster an environment in which differences are respected and that is responsive to the 

challenges a culturally and linguistically diverse staff brings into the workplace.

Resources 

American Medical Association, The Ethical Force Program. (2006). Content area 4. Develop workforce. In 

Improving communication—improving care: How health care organizations can ensure effective, 

patient-centered communication with people from diverse populations (pp. 47–54). Retrieved 

from http://www.ama-assn.org/resources/doc/ethics/pcc-consensus-report.pdf

American Medical Association. (2012). C-CAT: Patient centered communication. Retrieved from 

http://www.ama-assn.org\go\ccat

Institute for Diversity in Health Management. (2004). Strategies for leadership: Does your hospital reflect 

the community it serves? Diversity and cultural proficiency assessment tool for leaders. Retrieved 

from http://www.aha.org/content/00-10/diversitytool.pdf

Smedley, B. D., Stith-Butler, A., & Bristow, L. R. (2004). In the nation’s compelling interest: Ensuring 

diversity in the health-care workforce. Retrieved from 

http://www.nap.edu/openbook.php?record_id=10885&page=1

The Sullivan Commission on Diversity in the Healthcare Workforce. (2004). Missing persons: Minorities in 

the health professions. Retrieved from http://www.aacn.nche.edu/mediarelations/SullivanReport.pdf

Wynia, M. K., Johnson, M., McCoy, T. P., Passmore Griffin, L., & Osborn, C. Y. (2010). Validation of an 

organizational communication climate assessment toolkit. American Journal of Medical Quality, 

25(6), 436–443. doi:10.1177/1062860610368428

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.
National Standards for CLAS in Health and Health Care:

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Bibliography 

Cooper, L. A., & Powe, N. R. (2004). Disparities in patient experiences, health care processes, and 

outcomes: The role of patient-provider racial, ethnic, and language concordance. Retrieved from 

The Commonwealth Fund website: 

http://www.commonwealthfund.org/programs/minority/cooper_raceconcordance_753.pdf

Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. 

Retrieved from http://www.nap.edu/openbook.php?record_id=10260&page=R1

Institute of Medicine. (2004). In the nation’s compelling interest: Ensuring diversity in the health-care 

workforce. Retrieved from http://www.nap.edu/openbook.php?record_id=10885&page=1

The Joint Commission. (2010). Advancing effective communication, cultural competence, and patientand family-centered care: A roadmap for hospitals. Retrieved from 

http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

Passel, J. S., & Cohn, D. (2008). U.S. population projections: 2005-2050. Retrieved from the Pew 

Research Center website: http://pewsocialtrends.org/files/2010/10/85.pdf 

QSource, Underserved Quality Improvement Organization Support Center. (2005). CLAS Standards 

implementation tips. Retrieved from 

http://www.qsource.org/uqiosc/CLAS%20Standards%20Strategies%5B7AUG-2005%5D.pdf

Rose, P. R. (2011). Understanding cultural nuances and barriers to cultural appreciation. In P. R. Rose 

(Ed.), Cultural competency for health administration and public health (pp. 41–56). Sudbury, MA: 

Jones & Bartlett Publishers.

Smedley, B. D., & Mittman, I. S. (2011). The diversity benefit: How does diversity among health 

professionals address public needs? In R. A. Williams (Ed.), Healthcare disparities at the 

crossroads with healthcare reform (pp. 167–193). New York, NY: Springer.

The Sullivan Commission on Diversity in the Healthcare Workforce. (2004). Missing persons: Minorities in 

the health professions. Retrieved from http://www.aacn.nche.edu/mediarelations/SullivanReport.pdf

U.S. Department of Commerce, Census Bureau. (2011). Overview of race and Hispanic origin: 2010. 

Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf 

U.S. Department of Commerce, Vice President Al Gore’s National Partnership for Reinventing Government 

Benchmarking Study. (1999). Best practices in achieving workforce diversity. Retrieved from 

http://govinfo.library.unt.edu/npr/library/workforce-diversity.pdf

U.S. Department of Health and Human Services, Health Resources and Services Administration. (2006). 

The rationale for diversity in the health professions: A review of the evidence. Retrieved from 

http://bhpr.hrsa.gov/healthworkforce/reports/diversityreviewevidence.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

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U.S. Department of Health and Human Services, Office of Minority Health. (2001). National standards for 

culturally and linguistically appropriate services in health care: Final report. Retrieved from 

http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf

Whealin, J. M., & Ruzek, J. (2008). Program evaluation for organizational cultural competence in mental 

health practices. Professional Psychology: Research and Practice, 39, 320–328.

Wynia, M. K., Johnson, M., McCoy, T. P., Passmore Griffin, L., & Osborn, C. Y. (2010). Validation of an 

organizational communication climate assessment toolkit. American Journal of Medical Quality, 

25(6), 436–443. doi:10.1177/1062860610368428
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

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Standard 4: Educate and Train Governance, Leadership, and 

Workforce in CLAS

Standard 4 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Educate and train governance, leadership, and workforce in culturally and linguistically appropriate 

policies and practices on an ongoing basis.

Purpose 

The purposes of educating and training governance, leadership, and workforce in CLAS are:

o To prepare and support a workforce that demonstrates the attitudes, knowledge, and skills 

necessary to work effectively with diverse populations

o To increase the capacity of staff to provide services that are culturally and linguistically 

appropriate

o To assess the progress of staff in developing cultural, linguistic, and health literacy competency

o To foster an individual’s right to respect and nondiscrimination by developing and implementing 

education and training programs that address the impact of culture on health and health care

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Educate and train governance, leadership, and workforce in culturally and linguistically 

appropriate services

In order for CLAS to be fully implemented, education and training for professionals working in health and 

human services must be ongoing. Cultural and linguistic competency concepts — including effective 

communication and patient-, family-, and community-based practices — should be incorporated not only

into all formal educational curricula but also into new and existing staff training and curricula.

Ongoing education and staff training ensures that governance, leadership, and the workforce are 

equipped with adequate knowledge, tools, and skills to appropriately manage cross-cultural encounters 

with individuals (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003). Consistent integration of 
National Standards for CLAS in Health and Health Care:

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cultural and linguistic competency with existent educational and training curricula reinforces an 

organization’s commitment to providing CLAS and may increase buy-in across the organization based on 

improving recognition of the role culture and language play in the provision of care and services, 

including their roles in service efficiency, effectiveness, satisfaction, and outcomes (Rose, 2011; Wu & 

Martinez, 2006).

While cultural and linguistic competency should permeate all education, training, policies, procedures, 

and daily operations, opportunities to learn and hone specific CLAS-related knowledge and skills should 

also be available. For example, health profession students should learn about culturally specific 

information regarding disease incidence and prevalence or the effect of current and historical events on 

certain groups’ interactions with the health and health care system (Betancourt et al., 2003). In addition, 

training of governance, leadership, and workforce could include review of, and emphasis on, honing 

existing communication or other related skills necessary to work effectively in cross-cultural encounters. 

The Joint Commission’s Advancing Effective Communication, Cultural Competence, and Patient- and 

Family-Centered Care: A Roadmap for Hospitals (2010) states that efforts should include all relevant 

policies, services, and programs that pertain to care and services.

Education and training should be based on sound educational principles (e.g., adult learning), including 

pre- and post-training assessments, and be conducted by appropriately qualified individuals. For 

training, a knowledge-based, skill-based, or attitude-based approach should be adopted, based upon 

the needs and weaknesses of the organization, with the goal of ensuring the success of the training 

(Rose, 2011). Specific topics for training should be based on the responsibilities of each member of the 

workforce, leadership, or governance. Some common topics that might be relevant include (but are not 

limited to):

o Exploration of one’s own cultural background and the cultural backgrounds of the individuals and 

populations served (AMA, 2006)

o The importance of effective communication to health care outcomes (AMA, 2006)

o Elements of effective communication of staff with individuals or groups of different cultures and 

different languages, including how to work with interpreters and use available language services 

effectively

o Effects of differences between the cultures of staff and individuals on clinical and other workforce 

encounters

o Strategies and techniques for the identification and resolution of cross-cultural conflicts between 

staff and individuals or groups and a discussion of the organization’s complaint/grievance 

procedures (see Standard 14)
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o Effects of cultural differences among individuals and staff on access to care, service utilization, 

quality of care, health outcomes, and individuals’ satisfaction, including the importance of socioeconomic status, race, ethnicity, disability status, sexual orientation, gender identity and other 

factors

o Importance of learning about the care of, and services to, individuals with limited English 

proficiency, low health literacy, disabilities or special needs, and diverse religious and spiritual 

backgrounds

o Discussion regarding discrimination based on race, ethnicity, sex, national origin, socioeconomic 

status, disability status, religion, sexual orientation, gender identity

o Application of laws and provisions that pertain to the delivery of culturally and linguistically 

appropriate care and services, including the Affordable Care Act of 2010, Title VI of the Civil 

Rights Act of 1964, HHS’ Guidance to Federal Financial Assistance Recipients Regarding Title VI 

Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons

(HHS OCR, 2003), Executive Order 13166, and state-level legislation (Graves et al., 2007)

o Strategies for collecting race, ethnicity, sex, language, and disability status data in a sensitive 

manner

Finally, there are important potential risks in training about culture, which should be recognized and 

addressed. First, training must avoid simplistic generalizations that can lead to stereotyping of individuals 

from different cultural groups (AMA, 2006). Instead, training should “emphasize sensitivity to variations 

within populations as well as among populations, including individual variations in beliefs, expectations 

and preferred modes of communication” and “training should help all members of the workforce develop 

the knowledge and skills needed to explore these variations during the course of care or service” (AMA, 

2006, p53). Second, it is essential for training to be linked to a comprehensive organizational strategy 

around CLAS — to be clearly related to organization mission, goals, and objectives. Thus, training must 

be accompanied by coordinated initiatives to support data collection, performance improvement, and 

accountability. Training without an organization-wide commitment to CLAS may dilute the training’s longterm ability to cultivate individuals’ commitment to CLAS if the training establishes performance 

expectations that are not then supported throughout the organization.

Strategies for Implementation 

The following are possible implementation strategies for educating and training governance, leadership, 

and workforce on CLAS:
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o Engage staff in dialogues about meeting the needs of diverse populations (Wilson-Stronks & 

Galvez, 2007).

o Provide ongoing in-service training on ways to meet the unique needs of the population, 

including regular in-services on how and when to access language services for individuals with 

limited English proficiency (Wilson-Stronks & Galvez, 2007).

o Take advantage of internal and external resources available to educate governance, leadership, 

and workforce on cultural beliefs they may encounter (Wilson-Stronks & Galvez, 2007).

o Allocate resources to train current staff in cultural competency or as medical interpreters if they 

speak a second language, have completed language assessments, and show an interest in 

interpretation (QSource, 2005).

o Incorporate cultural competency and CLAS into staff evaluations (QSource, 2005).

o Provide opportunities for CLAS training that include regular in-services, brown-bag lunch series, 

orientation materials for new staff, and annual update meetings (QSource, 2005).

o Encourage staff to volunteer in the community and to learn about community members and other 

cultures (QSource, 2005), and work with community leaders and cultural brokers to create 

opportunities for such interactions.

o Evaluate education and training (see Standard 10).

o Take advantage of live and Web-based health disparities and cultural competency continuing 

education programs for clinicians and practitioners (Like, 2011).

Resources 

American Academy of Family Physicians. (2001). Quality care for diverse populations videos [Video 

series]. Available from 

http://www.aafp.org/online/en/home/clinical/publichealth/culturalprof/quality-care-diversepopulations.html

American Academy on Communication in Healthcare. (n.d.). Skills based courses [Course summaries]. 

Retrieved from http://www.aachonline.org/?page=SkillsBasedCourses

Cross Cultural Health Care Program. (n.d.). Course information: Bridging the gap [Online training course 

summary]. Retrieved from http://www.xculture.org/BTGclassdesc.php

Graves, D. L., Like, R. C., Kelly, N., & Hohensee, A. (2007). Legislation as intervention: A survey of 

cultural competence policy in health care. Journal of Health Care Law and Policy, 10(2), 339–361. 

Retrieved from http://thecqc.org/uploads/Graves_et_al.pdf
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Institute for Healthcare Communication. (2012). Training. Retrieved from 

http://healthcarecomm.org/training

Exec. Order No. 13,166, 3 C.F.R. 289 (2000).

Ring, J., Nyquist, J., Mitchell, S., Flores, H., & Samaniego, L. (2008). Curriculum for culturally responsive 

health care: The step-by-step guide for cultural competence training. Oxford, UK: Radcliffe 

Publishing.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. (n.d.). 

Training and continuing education online: Health literacy for public health professionals (webbased) [Online training course summary]. Retrieved from 

http://www2a.cdc.gov/tceonline/registration/detailpage.asp?res_id=2074

U.S. Department of Health and Human Services, Health Resources and Services Administration. (n.d.). 

Unified health communication 101. Retrieved from 

http://www.hrsa.gov/publichealth/healthliteracy/index.html

U.S. Department of Health and Human Services, Office for Civil Rights. (2003). Guidance to federal 

financial assistance recipients regarding Title VI and the prohibition against national origin 

discrimination affecting limited English proficient persons. Retrieved from 

http://www.hhs.gov/ocr/civilrights/resources/laws/revisedlep.html

U.S. Department of Health and Human Services, Office of Minority Health. (2005). A patient-centered 

guide to implementing language access services in healthcare organizations. Retrieved from 

http://minorityhealth.hhs.gov/Assets/pdf/Checked/HC-LSIG.pdf

U.S. Department of Health and Human Services, Office of Minority Health. (n.d.). A physician’s practical 

guide to culturally competent care. Retrieved from https://cccm.thinkculturalhealth.hhs.gov/

U.S. Department of Health and Human Services, Office of Minority Health. (n.d.). Cultural competency 

curriculum for disaster preparedness and crisis response. Retrieved from 

https://cccdpcr.thinkculturalhealth.hhs.gov/

U.S. Department of Health and Human Services, Office of Minority Health. (n.d.). Culturally competent 

nursing care: A cornerstone of caring. Retrieved from https://ccnm.thinkculturalhealth.hhs.gov/

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

American Medical Association. (2006). Improving communication, improving care: How health care 

organizations can ensure effective, patient-centered communication with people from diverse 

populations. Retrieved from http://www.ama-assn.org/resources/doc/ethics/pcc-consensusreport.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

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Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-Firempong, O. (2003). Defining cultural 

competence: A practical framework for addressing racial/ethnic disparities in health and health 

care. Public Health Reports, 118, 293–302. Retrieved from 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497553/pdf/12815076.pdf

Graves, D. L., Like, R. C., Kelly, N., & Hohensee, A. (2007). Legislation as intervention: A survey of 

cultural competence policy in health care. Journal of Health Care Law and Policy, 10(2), 339–361. 

Retrieved from http://thecqc.org/uploads/Graves_et_al.pdf

The Joint Commission. (2010). Advancing effective communication, cultural competence, and patientand family-centered care: A roadmap for hospitals. Retrieved from 

http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

Like, R. C. (2011). Educating clinicians about cultural competence and disparities in health and health 

care. Journal of Continuing Education in the Health Professions, 31(3), 196–206.

QSource, Underserved Quality Improvement Organization Support Center. (2005).CLAS Standards 

implementation tips. Retrieved from 

http://www.qsource.org/uqiosc/CLAS%20Standards%20Strategies%5B7AUG-2005%5D.pdf

Rose, P. R. (2011). Understanding cultural nuances and barriers to cultural appreciation. In P. R. Rose 

(Ed.), Cultural competency for health administration and public health (pp. 41–56). Sudbury, MA: 

Jones & Bartlett Publishers.

U.S. Department of Health and Human Services, Office for Civil Rights. (2003). Guidance to federal 

financial assistance recipients regarding Title VI prohibition against national origin discrimination 

affecting limited English proficient persons. Retrieved from 

http://www.hhs.gov/ocr/civilrights/resources/laws/revisedlep.html

Wilson-Stronks, A., & Galvez, E. (2007). Hospitals, language, and culture: A snapshot of the nation. 

Retrieved from The Joint Commission website: 

http://www.jointcommission.org/assets/1/6/hlc_paper.pdf

Wu, E., & Martinez, M. (2006). Taking cultural competency from theory to action (Commonwealth Fund 

Publication No. 964). Retrieved from The Commonwealth Fund website: 

http://www.commonwealthfund.org/usr_doc/Wu_takingcultcomptheoryaction_964.pdf
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Standard 5: Offer Communication and Language Assistance

Standard 5 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Offer language assistance to individuals who have limited English proficiency and/or other communication 

needs, at no cost to them, to facilitate timely access to all health care and services.

Purpose 

The purposes of offering communication and language assistance are:

o To ensure that individuals with limited English proficiency and/or other communication needs 

have equitable access to health services

o To help individuals understand their care and service options and participate in decisions

regarding their health and health care

o To increase individuals’ satisfaction and adherence to care and services

o To improve patient safety and reduce medical error related to miscommunication

o To help organizations comply with requirements such as Title VI of the Civil Rights Act of 1964; 

the Americans with Disabilities Act of 1990; and other relevant federal, state, and local 

requirements to which they may need to adhere

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Offer Language Assistance

Language assistance services are mechanisms used to facilitate communication with individuals who do 

not speak English, those who have limited English proficiency, and those who are deaf or hard of hearing. 

As noted in The Joint Commission’s Advancing Effective Communication, Cultural Competence, and 

Patient- and Family-Centered Care: A Roadmap for Hospitals, these services can include in-person 

interpreters, bilingual staff, or remote interpreting systems such as telephone or video interpreting, as 

well the translation of written materials or signage, sign language, or braille materials (The Joint 

Commission, 2010). Language assistance services facilitate the effective and accurate exchange of 
National Standards for CLAS in Health and Health Care:

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Standard 5 73

information between an individual with language and communication needs and his/her provider. By 

facilitating conversations regarding prevention, symptoms, diagnosis, treatment, and other issues, 

language assistance improves the quality of services and patient safety.

Language assistance services may be required by law for organizations that receive federal funds. In 

2000, the President signed Executive Order 13166, which requires all federal agencies, as well as all 

recipients of federal financial assistance, to take reasonable steps to ensure meaningful access for limited 

English proficient persons to the services and care provided by their agency or organization (Executive 

Order no. 13,166, 2000). This legal requirement stems from the national origin nondiscrimination 

provisions of Title VI of the Civil Rights Act of 1964 and its implementing regulations (Executive Order no. 

13,166, 2000).

Interpretation and translation can be delivered through a variety of means, depending upon the setting 

and the services being delivered. The following table compares and contrasts the acts of interpreting and 

translating. As with all culturally and linguistically appropriate services, it is important to monitor the 

quality and utilization of services.

Table 3: Interpreting and Translating

Question Interpreting Translating

Why

Interpreting overcomes language barriers 

to make communication possible.

Translating allows individuals who cannot read 

a specific language to obtain access to written 

information in their native tongue.

What

Quality interpreting reflects cultural terms, 

expressions, and idioms that have bearing 

on the meaning of the content. 

Interpreting must capture any 

expressions or nuances in meaning to 

maintain the impact of the original 

message.

Interpreting is an action that, once having 

taken place, is done.

Quality translating must reflect cultural terms, 

expressions, and idioms that have bearing on 

the meaning of the content. A translation must 

capture any expression or nuances in meaning 

to maintain the impact of the original message.

A translation is a product that is permanent 

and can be shared, stored, reviewed, and 

revised as often as desired.
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Question Interpreting Translating

Who

Interpreters commonly work by 

themselves as part of a triad with the 

patient and provider. Interpreters must 

have an advanced level of proficiency in 

both languages and must possess 

exceptional listening and memory skills 

for accuracy and completeness in verbal 

expression.

Special language aptitude is required in 

both the language of medical terminology 

and in health care systems. Traditionally, 

interpreters prepare and conduct research 

prior to the encounter, using resources 

such as dictionaries and consultation with 

professionals in a specific field to 

complete their work.

A translator usually works as a part of a 

translation team that consists of individuals 

with advanced levels of proficiency in both 

languages and with exceptional research skills 

to ensure accuracy in work. Translation teams 

include proofreaders and editors (and in some 

cases, desktop publishers, and project 

managers).

Special language aptitude is required in both 

the language of medical terminology and in 

health care systems. Translation teams also 

rely on dictionaries, consultation with 

professionals in a specific field, and other 

resources to complete their work.

How

Interpreters work “in the moment” and 

are compelled by the mode of 

interpreting. Interpreters may consult 

dictionaries or utilize other resources, but 

the time between each exchange is only a 

matter of seconds or minutes.

Interpreters work bidirectionally, going 

back and forth between two languages.

The interpreter functions as a conduit, 

clarifier, cultural broker, and advocate. 

Interpreters must be able to perform each 

role appropriately throughout the 

encounter.

Interpreters must be sensitive and 

considerate of both cultures. The goal is 

to have the listener understand the 

message as if it were heard directly from 

the original speaker.

The National Council for Interpreting in 

Health Care has published a Code of 

Ethics and Standards of Practice for 

interpreters (National Council on 

Interpreting in Health Care, 2004, 2005).

Translators work on a different timeframe. 

They must read an entire text for 

comprehension before starting the translation, 

often consulting dictionaries and other 

resources for correct grammar and 

terminology.

Most translators usually translate into their 

native language(s).

Translation is a process that requires analysis, 

conversion, proofreading, and editing.

Translators must be sensitive and considerate 

of both cultures. Localization is a specialized 

form of translation in which a completely 

adapted product (translation) takes into 

consideration differences in culture as well as 

language, whether that product is software, an 

Internet site, or a manufactured product. The 

goal is to produce a translation that appears to 

have been done originally in the target 

country.

The American Translators Association has 

issued a Code of Ethics and Professional 

Practice for translators (American Translators 

Association, n.d.).
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 5 75

Question Interpreting Translating

Where

Interpreting takes place at a specific time 

and place.

Interpreters work in public (in a hospital 

or clinic, for example) or in private (in the 

case of telephonic and video interpreters 

who work either from a home office or in 

a call center).

Interpreters must be present at a specific 

location; i.e., onsite at a hospital or clinic, 

or at a location that has dedicated 

resources for telephonic interpreting or 

video remote interpreting.

Translation can take place at any place and 

any time — only the final product is required to 

be at a specific place and time.

Translators work in any setting, from the 

offices of a large translation department to the 

privacy of their homes.

(National Health Law Program, 2010, pp. 3–4) 

Individuals who have limited English proficiency and/or other communication needs

Limited English proficiency is a concept referring to a level of English proficiency that is insufficient to 

ensure equal access to public services without language assistance with respect to a particular type of 

service, benefit, or encounter (HHS OCR, 2004). As discussed in Standard 1, individuals may have 

communication needs not related to a language barrier, such as those who are deaf or hard of hearing, 

visually impaired, or disabled or those with low health literacy.

The primary recipient of language assistance is often the individual receiving care or services; however, 

other individuals — such as family members or caregivers — may be involved in the provision of support 

or care to an individual. If family members or caregivers also have limited English proficiency and/or 

other communication needs, their linguistic needs should also be met to ensure the best outcomes for the 

individual receiving care. It is important to determine whether the individual’s medical decision-maker, 

health care proxy, or advocate has limited English proficiency, since these individuals may serve as the 

primary decision-makers regarding the care received by minors, aging parents, and/or individuals with 

disabilities (National Health Law Program, 2010).

Timely access to all health care and services

While there is no single definition for “timely” that is universally applicable, the HHS Office for Civil Rights 

is available to provide guidance and assistance to those seeking to understand timeliness in access to 

services. For example, the Office for Civil Rights notes that language assistance should be provided at a 

time and place that avoids the effective denial of the service, benefit, or right at issue or the imposition of 

an undue burden on, or delay in, important rights, benefits, or services to the limited English proficient 

person (HHS OCR, 2004).
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 5 76

Strategies for Implementation 

The following are possible implementation strategies for offering communication and language 

assistance:

o Ensure that staff is fully aware of, and trained in, the use of language assistance services, 

policies, and procedures (see Standard 4) (HHS OMH, 2005).

o Develop processes for identifying the language(s) an individual speaks (e.g., language 

identification flash cards or “I speak” cards) and for adding this information to that person’s 

health record (QSource, 2005).

o Use qualified and trained interpreters to facilitate communication (Wilson-Stronks & Galvez, 

2007), including ensuring the quality of the language skills of self-reported bilingual staff who use 

their non-English language skills during patient encounters (Regenstein, Andres, & Wynia, in 

press).

o Establish contracts with interpreter services for in-person, over-the-phone, and video remote 

interpreting (HHS OMH, 2005).

o Use cultural brokers when an individual’s cultural beliefs impact care communication (WilsonStronks & Galvez, 2007).

o Provide resources onsite to facilitate communication for individuals who experience impairment 

due to a changing medical condition or status (e.g., augmentative and alternative communication 

resources or auxiliary aids and services) as noted in Advancing Effective Communication, Cultural 

Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (The Joint 

Commission, 2010).

Resources 

American Medical Association. (2007). Office guide to communicating with limited English proficient 

patients. Retrieved from http://www.ama-assn.org/ama1/pub/upload/mm/433/lep_booklet.pdf

Andrulis, D. P., & Brach, C. (2007). Integrating literacy, culture, and language to improve health care 

quality for diverse populations. American Journal of Health Behavior, 31, S122–S133. Retrieved 

from http://www.cpehn.org/pdfs/Integrating%20Literace%20Paper%20-%20Andrulis.pdf

California Academy of Family Physicians. (2005). Addressing language access issues in your practice: A 

toolkit for physicians and their staff members. Retrieved from 

http://www.calendow.org/uploadedFiles/language_access_issues.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 5 77

Chen, A. H., Youdelman, M. K., & Brooks, J. (2007). The legal framework for language access in 

healthcare settings: Title VI and beyond. Journal of General Internal Medicine, 22(Supplement 2), 

362–367. doi:10.1007/s11606-007-0366-2

Divi, C., Koss, R. G., Schmaltz, S. P., & Loeb, J. M. (2007). Language proficiency and adverse events in 

US hospitals: A pilot study. International Journal of Quality in Health Care, 19(2), 60–67. 

doi:10.1093/intqhc/mzl069

The Joint Commission. (2010). Advancing effective communication, cultural competence, and patientand family-centered care: A roadmap for hospitals. Retrieved from 

http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

Limited English proficiency: A federal interagency website. (n.d.). Retrieved from http://www.lep.gov

Robert Wood Johnson Foundation. (2008). Speaking together toolkit. Retrieved from 

http://www.rwjf.org/pr/product.jsp?id=29653

U.S. Department of Health and Human Services, Office of Minority Health. (2005). A patient-centered 

guide to implementing language access services in healthcare organizations. Retrieved from 

http://minorityhealth.hhs.gov/Assets/pdf/Checked/HC-LSIG.pdf

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

American Translators Association. (n.d.). Code of ethics and professional practice. Retrieved from 

http://www.atanet.org/membership/code_of_ethics_commentary.pdf

Exec. Order No. 13,166, 3 C.F.R. 289 (2000).

The Joint Commission. (2010). Advancing effective communication, cultural competence, and patientand family-centered care: A roadmap for hospitals. Retrieved from 

http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

National Council on Interpreting in Health Care. (2004). A national code of ethics for interpreters in 

health care. Retrieved from http://www.oregon.gov/OHA/oei/intrprtr/docs/NCIHC_NCE.pdf

National Council on Interpreting in Health Care. (2005). National standards of practice for interpreters in 

health care. Retrieved from 

http://mchb.hrsa.gov/training/documents/pdf_library/National_Standards_of_Practice_for_Interpr

eters_in_Health_Care%20(12-05).pdf

National Health Law Program. (2010). What’s in a word? A guide to understanding interpreting and 

translation in health care. Retrieved from 

http://www.healthlaw.org/images/stories/whats_in_a_word_guide.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 5 78

QSource, Underserved Quality Improvement Organization Support Center. (2005). CLAS Standards 

implementation tips. Retrieved from 

http://www.qsource.org/uqiosc/CLAS%20Standards%20Strategies%5B7AUG-2005%5D.pdf

Regenstein, M., Andres, E., & Wynia, M. K., for the Commission to End Health Care Disparities. (in press). 

Safer use of physicians’ second language skills in caring for patients with limited English 

proficiency: A report of the Commission to End Health Care Disparities with recommendations for 

clinicians, organizations, and policymakers. Chicago: IL: American Medical Association.

U.S. Department of Health and Human Services, Office for Civil Rights. (2004). Limited English proficiency 

(LEP). Retrieved from http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/index.html

U.S. Department of Health and Human Services, Office of Minority Health. (2005). A patient-centered 

guide to implementing language access services in healthcare organizations. Retrieved from 

http://minorityhealth.hhs.gov/Assets/pdf/Checked/HC-LSIG.pdf

Wilson-Stronks, A., & Galvez, E. (2007). Hospitals, language, and culture: A snapshot of the nation.

Retrieved from The Joint Commission website: 

http://www.jointcommission.org/assets/1/6/hlc_paper.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 6 79

Standard 6: Inform Individuals of the Availability of Language 

Assistance

Standard 6 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Inform all individuals of the availability of language assistance services clearly and in their preferred 

language, verbally and in writing.

Purpose 

The purposes of informing individuals of the availability of language assistance are:

o To inform individuals with limited English proficiency, in their preferred language, that language 

services are readily available at no cost to them

o To facilitate access to language services

o To help organizations comply with requirements such as Title VI of the Civil Rights Act of 1964; 

the Americans with Disabilities Act of 1990; and other relevant federal, state, and local 

requirements to which they may need to adhere

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Inform all individuals of the availability of language assistance services

The provision of language assistance services is critical to ensuring quality, safety, satisfaction, and 

improved outcomes, and informing individuals that such services are available helps ensure their use. 

Organizations should take the appropriate steps to notify individuals of the availability of language 

assistance services and that they are available free of cost. Individuals in need of communication and 

language assistance may not know such services are available to them upon request. Commonly reported 

barriers to services among individuals who are limited English proficient include the lack of availability of 

language services or the lack of awareness that such services exist (Barr & Wanat, 2005; Flores, 2006). 

Thus, organizations should provide notification of the availability of language assistance services at 

various points of contact and by various means.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 6 80

Language assistance services may be required by law for organizations that receive federal funds. In 

2000, the President signed Executive Order 13166, which requires all federal agencies, as well as all 

recipients of federal financial assistance, to take reasonable steps to ensure meaningful access for limited 

English proficient persons to the services and care provided by their agency or organization (Executive 

Order no. 13,166, 2000). This legal requirement stems from the national origin nondiscrimination 

provisions of Title VI of the Civil Rights Act of 1964 and its implementing regulations (Executive Order no. 

13,166, 2000).

Organizations should provide the notification in the individual’s preferred language as determined by a 

language identification tool (e.g., “I speak” cards). Staff and providers speaking to individuals, whether in 

person or over the phone, should provide notification of the communication and language assistance 

available. Notifications should also be provided in print and multimedia materials that are easy to 

understand and translated into the languages commonly used by the populations in the service area 

(HHS OMH, 2005).

All members of the organization should be fully aware of the communication and language assistance 

services available, as well as all related organizational policies and procedures. To achieve this, all 

members of the organization should be trained in how to access communication and language assistance 

and work with language assistance personnel in order to support requests that come from individuals 

seeking health care and services (see Standard 4). Research conducted by the National Health Law 

Program identified staff training as essential to ensuring that available language services are 

appropriately utilized (Youdelman, Perkins, Brooks, & Reid, 2007), and another study demonstrated that 

more effective staff training is associated with significantly higher ratings on patient-reported quality of 

care and trust in the organization (Wynia et al., 2010). These trainings may be conducted in person 

onsite (as a part of existing training), or they may be a part of online training and information 

dissemination (Youdelman et al., 2007).

To ensure that the organization’s methods of providing notice of language assistance to individuals with 

limited English proficiency are effective, the organization should monitor, evaluate, and update the 

solutions on an ongoing basis. It may be important to consider the following questions:

o What factors are enablers and barriers to notifying individuals about available language 

assistance?

o What aspects of the language assistance notification process should be supported, encouraged, 

and replicated?

o What aspects of the language assistance notification process should be revised, improved, or 

eliminated?
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 6 81

o What are the recommendations for improving language assistance notification?

o Which of the recommendations should take priority in terms of implementation?

Strategies for Implementation 

The following are possible implementation strategies for informing individuals of the availability of 

language assistance:

The HHS Office of Minority Health’s A Patient-Centered Guide to Implementing Language Access Services 

in Healthcare Organizations (2005) identified the following strategies to effectively inform individuals of 

the availability of language assistance:

o Determine the content and language of notices

o Decide how to communicate or provide notice to individuals

o Decide where to provide notice to individuals about the availability of assistance

In determining the content and languages of the notices, organizations should consider the following:

o Notification should describe what communication and language assistance is available, in what 

languages the assistance is available, and to whom they are available. It should clearly state that 

communication and language assistance is provided by the organization free of charge to 

individuals (HHS OMH, 2005).

o Notification should be easy to understand at a low literacy level (HHS OMH, 2005).

In deciding how to communicate or provide notice to individuals about the availability of language 

services, organizations should consider the following:

o Signage, Materials, and Multimedia: Organizations should reflect the languages regularly 

encountered in the service area in their signs, materials, and multimedia resources (Berger, 

2005; HHS OCR, 2003). For those who may not be literate, information can be conveyed orally or 

through signage using symbols or pictures (HHS OMH, 2005; Kashiwagi, 2004).

o Cultural Mediation: Another method for promoting quality communication is through the 

development of a cultural mediation program. A cultural mediator can act as a liaison between 

the culture of the organization and the culture of the individual. An additional strategy for 

notifying individuals of language services through mediation is by developing a health promotion 

program (e.g., community health workers and promotores de salud) that includes bilingual staff 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 6 82

who train community members to share health and resource information with other community 

members (HHS OMH, 2005; Youdelman & Perkins, 2005;).

o Community Outreach: Providing notification throughout the community is also important for 

reaching those who may be unaware of the organization or what services the organization may 

provide. In accordance with Standard 13, consider sending notification through local health 

departments, community-based organizations, faith-based organizations, schools, or any other 

stakeholders who would benefit from having information on health services (HHS OCR, 2003; 

HHS OMH, 2005).

o Initial Point of Contact: It is recommended that organizations standardize procedures for staff 

members who serve as the initial point of contact for individuals, whether that is by telephone or 

in person. It may be appropriate to provide staff with a script to ensure that they inform 

individuals of the availability of language assistance and to inquire whether they will need to 

utilize any of the available services. Multilingual phone trees and voice mail should also be used 

to inform individuals of the available language assistance services and how to access them (HHS 

OCR, 2003; HHS OMH, 2005).

o Non-English Media: Organizations should publicize availability of language assistance services 

in local foreign language media, such as ethnic radio, newspapers, and television (HHS OMH, 

2005; Youdelman et al., 2007).

In deciding where to provide notice to individuals about the availability of language services, 

organizations should consider the following:

o Points of entry or intake, including:

• Registration desks

• Front desks

• Waiting rooms

• Financial screening rooms, where individuals may need to discuss and resolve billing 

issues

• Pharmacy reception, where individuals may pick up prescriptions

(HHS OMH, 2005; Kashiwagi, 2004;)

o Areas where clinical work is performed, such as triage and medical exam rooms (HHS OMH, 

2005).
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 6 83

Resources 

American Medical Association. (2007). Office guide to communicating with limited English proficient 

patients. Retrieved from http://www.ama-assn.org/ama1/pub/upload/mm/433/lep_booklet.pdf

Brach, C., Fraser, I., & Perez, K. (2005). Crossing the language chasm. Health Affairs, 24(2), 424–434. 

doi:10.1377/hlthaff.24.2.424

Chen, A. (2006). Doctoring across the language divide. Health Affairs, 25(3), 808–813. 

doi:10.1377/hlthaff.25.3.808

Limited English proficiency: A federal interagency website. (n.d.). Retrieved from http://www.lep.gov

Meyers, K., Tang, G., & Fernandez, A. (2009). Responding to the language challenge: Kaiser 

Permanente’s approach. The Permanente Journal, 13(3), 77–83. Retrieved from 

http://www.thepermanentejournal.org/files/Summer2009/language_challenge.pdf

National Association of the Deaf. (2012). Retrieved from http://www.nad.org/

Robert Wood Johnson Foundation. (n.d.). Shared decision-making when an interpreter is needed: A case 

study with Latino men at risk for prostate cancer (Grant details). Retrieved from 

http://www.rwjf.org/grants/grant.jsp?id=63830

U.S. Department of Health and Human Services, Office of Minority Health. (2005). A patient-centered 

guide to implementing language access services in healthcare organizations. Retrieved from 

http://minorityhealth.hhs.gov/Assets/pdf/Checked/HC-LSIG.pdf

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

Barr, D. A., & Wanat, S. F. (2005). Listening to patients: Cultural and linguistic barriers to health care 

access. Family Medicine, 37, 199–204. Retrieved from 

http://www.stfm.org/fmhub/fm2005/March/Donald199.pdf

Berger, C. (2005). Universal symbols in health care workbook. Retrieved from Hablamos Juntos website: 

http://www.hablamosjuntos.org/signage/PDF/Best%20Practices-FINALDec05.pdf

Exec. Order No. 13,166, 3 C.F.R. 289 (2000).

Flores, G. (2006). Language barriers to health care in the United States. New England Journal of 

Medicine, 355, 229–231. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp058316

Kashiwagi, S. (2004). A functional manual for providing linguistically competent health care services as 

developed by a community health center. Los Angeles, CA: Asian Pacific Health Care Venture, 

Inc.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 6 84

U.S. Department of Health and Human Services, Office for Civil Rights. (2003). Guidance to federal 

financial assistance recipients regarding Title VI and the prohibition against national origin 

discrimination affecting limited English proficient persons. Retrieved from 

http://www.hhs.gov/ocr/civilrights/resources/laws/revisedlep.html

U.S. Department of Health and Human Services, Office of Minority Health. (2005). A patient-centered 

guide to implementing language access services in healthcare organizations. Retrieved from 

http://minorityhealth.hhs.gov/Assets/pdf/Checked/HC-LSIG.pdf

Wynia, M. K., Johnson, M., McCoy, T. P., Passmore Griffin, L., & Osborn, C. Y. (2010). Validation of an 

organizational communication climate assessment toolkit. American Journal of Medical Quality, 

25(6), 436–443. doi:10.1177/1062860610368428

Youdelman, M., & Perkins, J. (2005). Providing language services in small health care provider settings: 

Examples from the field (Commonwealth Fund Publication No. 810). Retrieved from The 

Commonwealth Fund website: 

http://www.commonwealthfund.org/usr_doc/810_Youdelman_providing_language_services.pdf

Youdelman, M., Perkins, J., Brooks, J. D., & Reid, D. (2007). Providing language services in state and 

local health-related benefits offices: Examples from the field (Commonwealth Fund Publication 

No. 995). Retrieved from The Commonwealth Fund website: 

http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2007/Jan/Provid

ing%20Language%20Services%20in%20State%20and%20Local%20Health%20Related%20Bene

fits%20Offices%20%20Examples%20From%20the%20Fi/Youdelman_providinglanguagesvcsstat

elocalbenefitsoffices_995%20pdf.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 7 85

Standard 7: Ensure the Competence of Individuals Providing 

Language Assistance

Standard 7 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Ensure the competence of individuals providing language assistance, recognizing that the use of 

untrained individuals and/or minors as interpreters should be avoided.

Purpose 

The purposes of ensuring the competence of individuals providing language assistance are:

o To provide accurate and effective communication between individuals and providers

o To reduce misunderstanding, dissatisfaction, omission of vital information, misdiagnoses, 

inappropriate treatment, and patient safety issues due to reliance on staff or individuals that lack 

interpreter training

o To empower individuals to negotiate and advocate, on their own behalf, for important services 

via effective and accurate communication with health and health care staff

o To help organizations comply with requirements such as Title VI of the Civil Rights Act of 1964; 

the Americans with Disabilities Act of 1990; and other relevant federal, state, and local 

requirements to which they may need to adhere

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Ensure the competence of individuals providing language assistance

Before one can be considered qualified to interpret, translate, or provide other communication assistance, 

he/she must be assessed to determine his/her competence. Language ability alone does not qualify an 

individual to provide language assistance. Leading organizations in the field of language assistance, as 

reported by the National Health Law Program (2010), have identified the requisite skills and qualifications 

of interpreters as follows:

o Active listening skills
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 7 86

o Message conversion skills

o Clear and understandable speech delivery

o Familiarity with regionalisms and slang in both languages

o Ability to identify differences in meaning due to dialects or regionalisms to ensure effective and 

accurate message conversion

o Ability to communicate in all registers and at varying levels of formality

o Understanding of colloquialisms and idiomatic expressions in all working languages

o Working knowledge of anatomy and physiology

o Extensive knowledge of the vocabulary and terminology related to diagnosis, prevention, 

treatment, and management of illness and disease

o Understanding of key concepts in health care, such as confidentiality, informed consent, and 

patients’ rights

o Command of the vocabulary related to the provision of health care in both languages

A similar list of requisite skills and qualifications has also been compiled by the National Health Law 

Program (2010) for translators and is as follows:

o Intimate knowledge of their own native language

o Ability to write in the idiomatic and natural patterns of their native language

o Knowledge of the variety of fields in the health care system and of medical terminology; a basic 

knowledge of diseases, procedures, and medications; and knowledge of how the health care 

system, as a whole, functions

o Knowledge of their professional limits — especially, before agreeing to translate a document, 

being confident that they are qualified to translate it and can make an accurate assessment of 

the time it will take to complete the translation

o Good research skills and access to appropriate reference materials

o Expertise in various forms of written communication, from handwritten notes to digital

o Ability to translate medicolegal documents, such as informed consent forms and provisions of the 

Health Insurance Portability and Accountability Act
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 7 87

o Regular reading of professional literature in health care fields to maintain currency of information

o Continuous honing of translation skills through professional development courses or training

Use of untrained individuals and/or minors as interpreters should be avoided

Using ad hoc interpreters or untrained individuals and/or minors as interpreters may appear to be a 

convenient or reasonable option for the individual and provider alike. For service providers, using an ad 

hoc interpreter may appear to be advantageous because there may be little or no upfront financial cost 

associated with using untrained individuals and/or minors, and there may be little to no interruption in 

service delivery, since the untrained individual is likely readily available. However, the use of unqualified 

interpreters can have dire consequences. Grave errors have occurred when untrained individuals have 

been used as interpreters, including misdiagnoses and significant medical errors (Flores, 2005; Flores et 

al., 2003), which may place the individual at increased risk of significant injury or death. In one notable 

case, a first responder misinterpreted a single Spanish word, “intoxicado,” to mean "intoxicated" rather 

than its intended meaning of "feeling sick to the stomach." This led to a delay in diagnosis, which 

resulted in a potentially preventable case of quadriplegia, and ultimately, a significant malpractice 

settlement (Flores, 2006).

Untrained family, friends, minors, and staff often do not possess the necessary skills to provide 

meaningful language services. Moreover, given their relationship to the patient, the use of friends, family 

members, and minors may compromise the autonomy and confidentiality of the communication (AMA, 

2006; Diamond & Jacobs, 2010). There are numerous benefits to the utilization of trained interpreters. 

For example, research conducted in an emergency department found that the use of trained interpreters 

resulted in reduced return rates to the emergency department, increased clinic utilization, and lower 30-

day discharges, with no concurrent increase in length of stay or cost of visit (Bernstein et al., 2002).

The primary role of the interpreter is to act as the conduit of information between the provider and the 

recipient of care or services. Family and friends should be present as a means of support and shared 

decision-making if the individual so chooses. However, a loved one should not assume the additional 

burden and risk of interpretation errors. Children, especially minor children, may not have the cognitive or 

emotional maturity to function in the role of interpreter (Wilson-Stronks & Galvez, 2007). In addition, the 

use of children as interpreters has been found not only to place unnecessary tension in the parent-child 

relationship but also to place stress and emotional strain on the child (Flores, 2005, 2006; Jacobs, Kroll, 

Green, & David, 1995; Schenker, Lo, Ettinger, & Fernandez, 2008). Parents or caregivers may not want 

to share sensitive information with their children, and, therefore, health professionals may not be able to 

gather an accurate history. It can also be quite distressing for a friend, family member, or child to have 

to deliver poor prognostic information to the individual.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 7 88

The use of clinical and nonclinical staff who speak a non-English language but who are untrained in 

medical interpretation can pose potential safety risks (Regenstein et al., in press). Research has shown 

that when clinicians speak a non-English language, or when untrained bilingual staff is available, an 

important set of potential barriers can arise and hinder the effective and appropriate use of trained 

interpreters (Maul, Regenstein, Andres, Wright, & Wynia, 2012).

Strategies for Implementation 

Depending upon an organization’s size, scope, and mission, its language assistance strategies will differ. 

Organizations may opt to provide interpretation services through in-person interpreters and bilingual staff 

and providers or through technological or electronic means, including telephonic or video remote 

interpreting. Translation may be conducted primarily internally or may be contracted to external

organizations.

The following are possible implementation strategies for ensuring the competence of individuals providing 

language assistance:

o Assess the individual’s language ability. There exist many options for testing an individual’s ability 

to communicate in a foreign language. The following table summarizes two of the leading 

language proficiency scales, the American Council on the Teaching of Foreign Languages scale 

(ACTFL) and the Interagency Language Roundtable (ILR) scale (LinguaLinks Library, 1999):

ILR Scale ACTFL Scale Definition

5 Native Able to speak like an educated native speaker

4+

4

Distinguished Able to speak with a great deal of fluency, grammatical 

accuracy, precision of vocabulary and idiomaticity

3+

3

Superior Able to speak the language with sufficient structural accuracy 

and vocabulary to participate effectively in most formal and 

informal conversations

2+ Advanced Plus Able to satisfy most work requirements and show some ability to 

communicate on concrete topics

2 Advanced Able to satisfy routine social demands and limited work 

requirements

1+ Intermediate - High Able to satisfy most survival needs and limited social demands
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 7 89

ILR Scale ACTFL Scale Definition

1 Intermediate – Mid

Intermediate - Low

Able to satisfy some survival needs and some limited social 

demands

Able to satisfy basic survival needs and minimum courtesy 

requirements

0+ Novice - High Able to satisfy immediate needs with learned utterances

0 Novice - Mid

Novice - Low

0

Able to operate in only a very limited capacity

Unable to function in the spoken language

No ability whatsoever in the language

o Assess the individual’s ability to provide language assistance. The American Translators 

Association upholds standards of practice for translation services (n.d.). Similarly, the National 

Council on Interpreting in Health Care has issued standards of practice that define expectations 

of performance and outcomes for health care interpreters (2005). In addition, the Certification 

Commission for Healthcare Interpreters and the National Board for Certification of Medical 

Interpreters provide national certification for interpreters.

The standards of practice identified by these professional organizations may offer promising 

practices in the provision of linguistically appropriate services. Keeping these standards at the 

core of hiring, training, and evaluating individuals will help ensure their competence in providing 

language assistance.

o Employ a “multifaceted model” of language assistance. Organizations may provide language 

assistance according to a variety of models, including bilingual staff or dedicated language 

assistance (e.g., a contract interpreter or video remote interpreting). A combination of models, or 

a multifaceted model, offers the organization a “comprehensive and flexible system [for] 

facilitating communication” (National Council on Interpreting in Health Care, 2002, p. 4). Under a 

multifaceted model, for example, telephonic interpreting will supplement the language assistance 

provided by bilingual staff to ensure that at all times, language assistance is being provided by 

competent individuals.

Resources 

California Healthcare Interpreting Association. (n.d.). Retrieved from http://chiaonline.org/
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 7 90

Certification Commission for Healthcare Interpreters. (n.d.). Retrieved from 

http://www.healthcareinterpretercertification.org/

Commonwealth of Massachusetts Executive Office of Health and Human Services, Massachusetts 

Department of Public Health. (2004). Best practice recommendations for hospital-based 

interpreter services. Retrieved from 

http://www.hablamosjuntos.org/pdf_files/Best_Practice_Recommendations_Feb2004.pdf

Hablamos Juntos. (2008). Language testing options 2008. Retrieved from 

http://www.imiaweb.org/uploads/pages/218.pdf

International Medical Interpreters Association. (1995). Medical interpreting standards of practice.

Retrieved from http://www.hablamosjuntos.org/resources/pdf/IMIA_Standards_Of_Practice.pdf

Limited English proficiency: A federal interagency website. (n.d.). Retrieved from http://www.lep.gov

National Board of Certification for Medical Interpreters. (2012). Retrieved from 

http://www.certifiedmedicalinterpreters.org/

National Council on Interpreting in Health Care. (2001). Guide to initial assessment of interpreter 

qualifications. Retrieved from 

http://data.memberclicks.com/site/ncihc/NCIHC%20Working%20Paper%20Guide%20to%20Initi

al%20Assessment%20of%20Interpreter%20Qualifications.pdf

Registry of Interpreters for the Deaf. (2012). Standard practice papers. Retrieved from 

http://www.rid.org/interpreting/Standard%20Practice%20Papers/index.cfm

Robert Wood Johnson Foundation. (2008). Kaiser Permanente’s health care interpreter certificate 

program. Retrieved from http://www.rwjf.org/pr/product.jsp?id=34036

Robert Wood Johnson Foundation. (2008). Kaiser Permanente’s qualified bilingual staff model. Retrieved 

from http://www.rwjf.org/pr/product.jsp?id=34030

Trott, J., West, C., Shah, P., & Regenstein, M. (2008). Building a high-quality language services program 

toolkit. Retrieved from http://www.lawhelp.org/documents/391611Building%20a%20HighQuality%20Language%20Services%20Program%20Toolkit.pdf

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

American Medical Association. (2006). Improving communication, improving care: How health care 

organizations can ensure effective, patient-centered communication with people from diverse 

populations. Retrieved from http://www.ama-assn.org/resources/doc/ethics/pcc-consensusreport.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 7 91

American Translators Association. (n.d.). Code of ethics and professional practice. Retrieved from 

http://www.atanet.org/membership/code_of_ethics_commentary.pdf

Bernstein, J., Bernstein, E., Dave, A., Hardt, E., James, T., Linden, J., Mitchell, P., Oishi, T., & Safi, C. 

(2002). Trained medical interpreters in the emergency department: effects on services, 

subsequent charges, and follow-up. Journal of Immigrant Health, 4(4), 171-176.

Diamond, L. C., & Jacobs, E. A. (2010). Let’s not contribute to disparities: The best methods for teaching 

clinicians how to overcome language barriers to health care. Journal of General Internal 

Medicine, 25(Supplement 2), S189–S193. Retrieved from 

http://www.springerlink.com/content/00h67538730pl426/fulltext.pdf

Flores, G. (2005). The impact of medical interpreter services on the quality of health care: A systematic 

review. Medical Care Research and Review, 62, 255–299.

Flores, G. (2006). Cases from AHRQ WebM&M: Language barriers are more than an inconvenience. 

Patient errors range from simple miscommunication to life-threatening. Retrieved from 

http://www.medscape.com/viewarticle/534045 

Flores, G. (2006). Language barriers to health care in the United States. New England Journal of 

Medicine, 355, 229–231. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp058316

Flores, G., Laws, M. B., Mayo, S. J., Zuckerman, B., Abreu, M., Medina, L., & Hardt, E. J. (2003). Errors in 

medical interpretation and their potential clinical consequences in pediatric encounters. 

Pediatrics, 111, 6–14.

Jacobs, B., Kroll, L., Green, J., & David, T. J. (1995). The hazards of using a child as an interpreter. 

Journal of the Royal Society of Medicine, 88, 474P–475P. Retrieved from 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295307/pdf/jrsocmed00067-0056.pdf

LinguaLinks Library. (1999). Correspondence of proficiency scales. Retrieved from 

http://www.sil.org/lingualinks/LANGUAGELEARNING/MangngYrLnggLrnngPrgrm/Correspondence

OfProficiencySca.htm 

Maul, L., Regenstein, M., Andres, E., Wright, R., & Wynia, M. K. (2012). Using a risk assessment 

approach to determine which factors influence whether partially bilingual physicians rely on their 

non-English language skills or call an interpreter? The Joint Commission Journal on Quality and 

Patient Safety, 38 (7), 328-336. 

National Council on Interpreting in Health Care. (2002). Models for the provision of language access in 

health care settings. Retrieved from 

http://data.memberclicks.com/site/ncihc/NCIHC%20Working%20Paper%20-

%20Models%20for%20Provision%20of%20Language%20Access.pdf 

National Council on Interpreting in Health Care. (2005). National standards of practice for interpreters in 

health care. Retrieved from 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 7 92

http://mchb.hrsa.gov/training/documents/pdf_library/National_Standards_of_Practice_for_Interpr

eters_in_Health_Care%20(12-05).pdf

National Health Law Program. (2010). What’s in a word? A guide to understanding interpreting and 

translation in health care. Retrieved from 

http://www.healthlaw.org/images/stories/Whats_in_a_Word_Guide.pdf

Regenstein, M., Andres, E., & Wynia, M. K., for the Commission to End Health Care Disparities. (in press). 

Safer use of physicians’ second language skills in caring for patients with limited English 

proficiency: A report of the Commission to End Health Care Disparities with recommendations for 

clinicians, organizations, and policymakers. Chicago, IL: American Medical Association.

Schenker, Y., Lo, B., Ettinger, K. M., & Fernandez, A. (2008). Navigating language barriers under difficult 

circumstances. Annals of Internal Medicine, 149, 264–269.

Wilson-Stronks, A., & Galvez, E. (2007). Hospitals, language, and culture: A snapshot of the nation. 

Retrieved from The Joint Commission website: 

http://www.jointcommission.org/assets/1/6/hlc_paper.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 8 93

Standard 8: Provide Easy-to-Understand Materials and Signage

Standard 8 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Provide easy-to-understand print and multimedia materials and signage in the languages commonly used 

by the populations in the service area.

Purpose 

The purposes of providing easy-to-understand materials and signage are:

o To ensure that readers of other languages and individuals with various health literacy levels are 

able to access care and services

o To provide access to health-related information and facilitate comprehension of, and adherence 

to, instructions and health plan requirements

o To enable all individuals to make informed decisions regarding their health and their care and 

services options

o To offer an effective way to communicate with large numbers of people and supplement 

information provided orally by staff members

o To help organizations comply with requirements such as Title VI of the Civil Rights Act of 1964; 

the Americans with Disabilities Act of 1990; and other relevant federal, state, and local 

requirements to which they may need to adhere

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Provide easy-to-understand print and multimedia materials and signage

Print and multimedia materials offer an effective way of communicating with large numbers of people, 

supplementing information provided by clinicians, service providers, and other staff, and reinforcing key 

messages from a health care or service encounter. Therefore, ensuring that an individual can read, 

comprehend, and act upon written materials is essential.
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Standard 8 94

Unfortunately, many health materials are written at a level too high for the average consumer to 

understand (Rudd, Moeykens, & Colton, 2000). The challenge to understand health materials is even 

greater for the one-third of adults with limited health literacy (HHS ODPHP, 2010). Minority populations 

are disproportionately represented among those with basic or below basic health literacy skills (Kutner et 

al., 2006), and the failure to address health literacy may exacerbate disparities (Koh et al., 2012). Health 

literate organizations design and distribute print, audiovisual, and social media content that is easy to 

understand and act on (Brach et al., 2012). Such materials use appropriate graphics, employ userfriendly design, focus on actionable information, and refrain from using jargon. Processes should be 

established to develop and select materials appropriate for the population served. The National Action 

Plan to Improve Health Literacy lays out strategies for developing and disseminating health and safety 

information that is accurate, accessible, and actionable (HHS ODPHP, 2010). Health materials should be 

used effectively as part of an educational strategy rather than becoming a substitute for spoken 

instruction (AHRQ, 2010). Similarly, clear signage does not obviate the need for other navigational 

assistance.

It is also important to translate materials that are essential to individuals’ accessing and making educated 

decisions about health care, including materials on the internet. Examples of relevant materials include:

o Administrative and legal documents — materials requiring informed consent, obligation, or 

acknowledgment of certain legal or financial rights and responsibilities; waivers of rights; living 

wills and advance directives; emergency room release and discharge forms; marketing materials; 

documents establishing and maintaining eligibility for services; explanations of benefit coverage 

packages; evidence of coverage cards; and notices of noncoverage

o Clinical information — prevention and treatment instructions, including how to prevent 

transmission of a communicable disease; what to do before, during, and after a procedure or 

treatment (e.g., surgery, chemotherapy); how to take medicine; and how to perform routine selfcare or self-monitoring

o Education, health prevention and promotion, and outreach materials — brochures, fact 

sheets, pamphlets, promotional flyers and posters, health advisories, and other materials that 

support treatment programs (e.g., for chronic disease or mental health) and prevention activities 

(e.g., cancer or high blood pressure screenings)

Multilingual signage in the languages of the populations in the service area should provide notices of 

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

addition, wayfinding signage should identify or label the location of specific services.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 8 95

Languages commonly used by the populations in the service area

Easy-to-understand print and multimedia materials and signage should be provided in the languages 

commonly used by populations in the service area. The HHS Office for Civil Rights offers guidance for 

organizations that receive federal funds to identify the language assistance services that need to be 

provided. This guidance will help health and health care organizations determine which documents and 

languages are to be addressed. The HHS Office for Civil Rights’ individualized assessment strategy 

balances four factors (HHS OCR, 2003):

1. The number or proportion of limited English proficient persons eligible to be served or likely to be 

encountered by the program or grantee

2. The frequency with which individuals with limited English proficiency come into contact with the 

program

3. The nature and importance of the program, activity, or service provided by the recipient to its 

beneficiaries

4. The resources available to the grantee/recipient and the costs of interpretation/translation 

services. There is no one-size-fits-all solution for Title VI compliance with respect to limited 

English proficient persons, and what constitute reasonable steps for large providers may not be 

reasonable where small providers are concerned.

According to guidance from the HHS Office for Civil Rights, organizations that receive federal funds may 

be required to take reasonable steps to ensure meaningful access to their programs and activities by 

limited English proficient persons. What constitutes meaningful access is made on a case-by-case basis, 

and therefore all organizations should determine their level of responsibility by conducting the four-factor 

analysis outlined above and developing a language assistance plan (HHS OCR, 2003).

Strategies for Implementation 

The following are possible implementation strategies for providing easy-to-understand materials and 

signage:

o Issue plain language guidance and create documents that demonstrate best practices in clear 

communication and information design (HHS ODPHP, 2010).

o Create forms that are easy to fill out, and offer assistance in completing forms (AHRQ, 2010).

o Consult local librarians to help build an appropriate collection of health materials (HHS ODPHP, 

2010).
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Standard 8 96

o Train staff to develop and identify easy-to-understand materials, and establish processes for 

periodically re-evaluating and updating materials (AHRQ, 2010).

o Formalize processes for translating materials into languages other than English and for evaluating 

the quality of these translations (Wilson-Stronks & Galvez, 2007).

o Develop materials in alternative formats for individuals with communication needs, including 

those with sensory, developmental, and/or cognitive impairments as noted in Advancing Effective 

Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for 

Hospitals (The Joint Commission, 2010).

o Test materials with target audiences. For example, focus group discussions with members of the 

target population can identify content in the material that might be embarrassing or offensive, 

suggest cultural practices that provide more appropriate examples, and assess whether graphics 

reflect the diversity of the target community. Organizations should consider providing financial 

compensation or in-kind services to community members who help translate and review materials 

(HHS OMH, 2001).

Resources 

Centers for Medicare & Medicaid Services. (2011). The toolkit for making written material clear and 

effective: Overview. Retrieved from https://www.cms.gov/WrittenMaterialsToolkit/

Downing, B., & Bogoslaw, L. (2003). Translation as a strategy for effective communication with patients 

and clients: A how-to guide. Retrieved from Hablamos Juntos website: 

http://www.hablamosjuntos.org/pdf_files/BruceDowningHow-To_Guide_FINAL.pdf

Harvard School of Public Health. (2010). Health literacy studies: Assessing and developing health 

materials. Retrieved from http://www.hsph.harvard.edu/healthliteracy/practice/innovativeactions/index.html

Health Literacy Innovations. (2008). The health literacy & plain language resource guide. Retrieved from 

http://www.healthliteracyinnovations.com/information/RGdownload

Limited English proficiency: A federal interagency website. (n.d.). Retrieved from http://www.lep.gov

National Council on Interpreting in Health Care. (2010). Sight translation and written translation: 

Guidelines for healthcare interpreters. Retrieved from 

http://data.memberclicks.com/site/ncihc/Translation%20Guidelines%20for%20Interpreters%20R

EVISED%2031710.pdf

National Health Law Program. (2010). What’s in a word? A guide to understanding interpreting and 

translation in health care. Retrieved from 

http://www.healthlaw.org/images/stories/whats_in_a_word_guide.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 8 97

Osborne, H. (2001, November). In other words...Can they understand? Testing patient education 

materials with intended readers. Retrieved from 

http://www.healthliteracy.com/article.asp?PageID=3811 (Reprinted from the Boston Globe On 

Call magazine)

Pierce, L. (2010). How to choose and develop written educational materials. Rehabilitation Nursing, 

35(3), 99–105. Retrieved from http://www.rehabnurse.org/pdf/rnj320.pdf

Plain Language Association International. (2011). Retrieved from http://www.plainlanguagenetwork.org/

Txabarriaga, R. (2009). IMIA guide on medical translation. Retrieved from International Medical 

Interpreters Association website: http://www.imiaweb.org/uploads/pages/438.pdf

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2010). 

Health literacy universal precautions toolkit (AHRQ Publication No. 10-0046-EF). Retrieved from 

http://www.ahrq.gov/qual/literacy/ 

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

American Medical Association. (2006). Improving communication, improving care: How health care 

organizations can ensure effective, patient-centered communication with people from diverse 

populations. Retrieved from http://www.ama-assn.org/resources/doc/ethics/pcc-consensusreport.pdf

Brach, C., Dreyer, D., Schyve, P., Hernandez, L. M., Baur, C., Lemerise, A. J., & Parker, R. (2012). 

Attributes of a health literate organization. Retrieved from: 

http://www.iom.edu/~/media/Files/Perspectives-Files/2012/DiscussionPapers/BPH_HLit_Attributes.pdf

The Joint Commission. (2010). Advancing effective communication, cultural competence, and patientand family-centered care: A roadmap for hospitals. Retrieved from 

http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

Koh, H. K., Berwick, D. M., Clancy, C. M., Baur, C., Brach, C., Harris, L. M., & Zerhusen, E. G. (2012). 

New federal policy initiatives to boost health literacy can help the nation move beyond the cycle 

of costly ‘crisis care’. Health Affairs, 31(2), 434–443.

Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America’s adults: Results 

from the 2003 National Assessment of Adult Literacy (NCES 2006–483). Washington, DC: 

National Center for Education Statistics.

Rudd, R., Moeykens, B. A., & Colton, T. C. (2000). Health and literacy: A review of the medical and public 

health literature. In J. Comings, B. Gerners, & C. Smith (Eds.), Annual review of adult learning 

and literacy (pp. 175-203). New York: Jossey-Bass.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 8 98

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2010). 

Health literacy universal precautions toolkit (AHRQ Publication No. 10-0046-EF). Retrieved from 

http://www.ahrq.gov/qual/literacy/ 

U.S. Department of Health and Human Services, Office for Civil Rights. (2003). Guidance to federal 

financial assistance recipients regarding Title VI and the prohibition against national origin 

discrimination affecting limited English proficient persons. Retrieved from 

http://www.hhs.gov/ocr/civilrights/resources/laws/revisedlep.html

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 

(2010). National action plan to improve health literacy. Retrieved from 

http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf

U.S. Department of Health and Human Services, Office of Minority Health. (2001). National standards for 

culturally and linguistically appropriate services in health care: Final report. Retrieved from 

http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf

Wilson-Stronks, A., & Galvez, E. (2007). Hospitals, language, and culture: A snapshot of the nation. 

Retrieved from The Joint Commission website: 

http://www.jointcommission.org/assets/1/6/hlc_paper.pdf
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 9 99

Standard 9: Infuse CLAS Goals, Policies, and Management 

Accountability Throughout the Organization’s Planning and 

Operations

Standard 9 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Establish culturally and linguistically appropriate goals, policies, and management accountability, and 

infuse them throughout the organization’s planning and operations.

Purpose 

The purposes of infusing CLAS throughout the organization’s planning and operations are:

o To make CLAS central to the organization’s service, administrative, and supportive functions

o To integrate CLAS throughout the organization (including the mission) and highlight its 

importance through specific goals

o To link CLAS to other organizational activities, including policy, procedures, and decision-making 

related to outcomes accountability

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Establish culturally and linguistically appropriate goals, policies, and management 

accountability

Establishing goals, policies, and management accountability that promote CLAS throughout an 

organization helps to ensure that an organization is culturally and linguistically competent at every point 

of contact and ties CLAS to organizational priorities such as individuals’ experiences, satisfaction, safety, 

and outcomes. This also illustrates the relevance of CLAS even in times of budgetary constraints and 

limited resources (Wu & Martinez, 2006). In addition, this integrated approach demonstrates to the 

community that cultural and linguistic competency is integral to the organization’s mission and vision.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 9 100

Infuse CLAS throughout the organization’s planning and operations

Culturally and linguistically appropriate services should be embedded throughout all levels of the 

organization—from the top down and from the bottom up. The entire health or health care organization 

affects quality of services and health outcomes of individuals; therefore, the entire organization should 

fully integrate CLAS- and health equity–related concepts and ideals. Different departments, policies, and 

roles should coordinate with and complement each other to this end.

Health and health care organizations should incorporate CLAS goals, policies, and accountability 

procedures at all levels by making them key aspects of the organization’s planning and operations 

(Weech-Maldonado, 2002). Organizations are encouraged to embed CLAS as a core element of the 

organization’s identity, mission, operating principles, service focus, budget, and quality improvement 

activities (AMA, 2006). For example, a health organization might collect and merge individual-level 

demographic data and quality improvement measures together to illustrate equitable health care as a 

quality improvement goal (Wilson-Stronks & Galvez, 2007).

In addition, organizations should establish a method (or procedure) of accountability for CLAS activities 

throughout the organization’s hierarchy, from the front desk to the senior executive level. All members of 

the organization should be trained and supported in making their day-to-day responsibilities culturally and 

linguistically appropriate and should be evaluated based on criteria relevant to CLAS and their role(s) 

within the organization (see Standard 4).

The National Quality Forum includes integration of cultural competency into management systems and 

operations as one of its seven primary domains for measuring and reporting cultural competency. 

Specifically, the National Quality Forum notes that a focus “on whether cultural competency is integrated 

throughout all management and operations activities of the organization is an essential component of 

supporting the delivery of culturally competent care” (National Quality Forum, 2009, p. iv).

Strategies for Implementation 

The following are possible implementation strategies for infusing CLAS goals, policies, and management 

accountability throughout the organization’s planning and operations:

o Engage the support of governance and leadership, and encourage the allocation of resources to 

support the development, implementation, and maintenance of culturally and linguistically 

appropriate services.

o Encourage governance and leadership to establish education and training requirements relating 

to culturally and linguistically appropriate services for all individuals in the organization, including 

themselves.
National Standards for CLAS in Health and Health Care:

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Standard 9 101

o Identify champions within and outside the organization to advocate for CLAS, to emphasize the 

business case and rationale for CLAS, and encourage full-scale implementation.

o Hold organizational retreats to identify goals, objectives, and timelines to provide culturally and 

linguistically appropriate services.

o Establish accountability mechanisms throughout the organization, including staff evaluations, 

individuals’ satisfaction measures, and quality improvement measures (QSource, 2005).

o Utilize the data gathered based on Standards 10, 11, and 12 to guide plan development.

o In accordance with Standard 13, involve the populations in the service area in the 

implementation of CLAS through the strategic plan.

Resources 

Betancourt, J. R., Weissman, J. S., Kim, M. K., Park, E., & Maina, A. W. (2007). Resident physicians’ 

preparedness to provide cross-cultural care: Implications for clinical care and medical education 

policy. Retrieved from The Commonwealth Fund website: 

http://www.commonwealthfund.org/usr_doc/1026_Betancourt_resident_MDs_preparedness_prov

ide_cross-cultural_care.pdf

The Joint Commission. (2007). “What did the doctor say?”: Improving health literacy to protect patient 

safety. Retrieved from 

http://www.jointcommission.org/assets/1/18/improving_health_literacy.pdf

Roat, C. (2003). How to choose and use a language agency: A guide for health and social service 

providers who wish to contract with language agencies. Retrieved from The California 

Endowment website:

http://www.calendow.org/uploadedFiles/how_to_choose_use_language_agency.pdf

Weech-Maldonado, R. (2007, June). Moving towards culturally competent health systems: Organizational 

and market factors. Presented at the AcademyHealth Disparities Interest Group Meeting, Miami, 

FL. Retrieved from http://www.academyhealth.org/files/interestgroups/disparities/weechmaldonador.pdf

Wilson-Stronks, A., & Galvez, E. (2007). Hospitals, language, and culture: A snapshot of the nation.

Retrieved from The Joint Commission website: 

http://www.jointcommission.org/assets/1/6/hlc_paper.pdf

Wu, E., & Martinez, M. (2006). Taking cultural competency from theory to action (Commonwealth Fund 

Publication No. 964). Retrieved from The Commonwealth Fund website: 

http://www.commonwealthfund.org/usr_doc/Wu_takingcultcomptheoryaction_964.pdf

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 9 102

Bibliography 

American Medical Association. (2006). Improving communication, improving care: How health care 

organizations can ensure effective, patient-centered communication with people from diverse 

populations. Retrieved from http://www.ama-assn.org/resources/doc/ethics/pcc-consensusreport.pdf

National Quality Forum. (2009). A comprehensive framework and preferred practices for measuring and 

reporting cultural competency: A consensus report. Retrieved from 

http://www.qualityforum.org/Publications/2009/04/A_Comprehensive_Framework_and_Preferred

_Practices_for_Measuring_and_Reporting_Cultural_Competency.aspx

QSource, Underserved Quality Improvement Organization Support Center. (2005). CLAS Standards 

implementation tips. Retrieved from 

http://www.qsource.org/uqiosc/CLAS%20Standards%20Strategies%5B7AUG-2005%5D.pdf

Weech-Maldonado, R. (2002). Organizational support standards for culturally and linguistically 

appropriate services (CLAS): Core concepts, content knowledge, and core skills. Retrieved from 

https://www.thinkculturalhealth.hhs.gov/pdfs/PhysiciansConceptPaper_Weech_Maldanado.pdf 

Wilson-Stronks, A., & Galvez, E. (2007). Hospitals, language, and culture: A snapshot of the nation. 

Retrieved from The Joint Commission website: 

http://www.jointcommission.org/assets/1/6/hlc_paper.pdf

Wu, E., & Martinez, M. (2006). Taking cultural competency from theory to action (Commonwealth Fund 

Publication No. 964). Retrieved from The Commonwealth Fund website: 

http://www.commonwealthfund.org/usr_doc/Wu_takingcultcomptheoryaction_964.pdf
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A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Standard 10 103

Standard 10: Conduct Organizational Assessments

Standard 10 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related 

measures into measurement and continuous quality improvement activities.

Purpose 

The purposes of conducting organizational assessments are:

o To assess performance and monitor progress in implementing the National CLAS Standards

o To obtain information about the organization and the people it serves, which can be used to 

tailor and improve services

o To assess the value of CLAS-related activities relative to the fulfillment of governance, leadership, 

and workforce responsibilities

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Conduct ongoing assessment of the organization’s CLAS-related activities

In general, the continuous quality improvement process for CLAS includes an assessment phase, a 

planning phase, an implementation phase, and an evaluation phase (Briefer French et al., 2008). As a key 

initial step in the continuous quality improvement process, organizational self-assessment is often used to 

examine factors that might enable or impede a service delivery system’s effectiveness and performance. 

It is essential for planning, implementing, and evaluating the quality of any kind of service, including 

CLAS. To address organizational readiness for providing CLAS, The Joint Commission’s Advancing 

Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for 

Hospitals (2010) calls on hospitals to “conduct an organization assessment that measures baseline 

performance on specific issues to know where improvement might be necessary, detect gaps and areas 

of excellence, and tailor improvement interventions.”

Organizational assessments range in intensity from relatively brief self-assessments using input solely 

from those in supervisory and/or administrative positions (e.g., organizational checklists), to in-depth 
National Standards for CLAS in Health and Health Care:

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assessments with structured and formal input from stakeholders, patients, consumers, and/or staff. In 

addition, they employ data collection methods ranging from informal interviews with senior leaders to 

using validated surveys across the organization. Ultimately, they produce outputs ranging from general 

and broad guidance to benchmarked and validated scores across multiple domains of performance.

A cultural audit is an assessment strategy used to examine, among other factors, an organization’s 

values, symbols, and routines and identify problems that affect the organization’s ability to provide 

services (Rice, 2005, 2008). A cultural audit may be used specifically to develop CLAS. With regard to 

cultural and linguistic competency, many organizations may remain largely unaware of structural, 

procedural, and behavioral factors that create barriers to providing quality services for diverse 

populations. A cultural audit and self-assessment may increase awareness within the organization by 

facilitating the identification of unique group characteristics that can be used to ensure service access and 

treatment and the identification of opportunities for the organization to better market itself to diverse 

populations (Andrulis, Delbanco, Avakian, & Shaw-Taylor, 2001). Although many health and health care 

organizations are attempting to provide CLAS through targeted programs, research suggests that they 

rarely perform optimally across the range of issues associated with CLAS (Wynia et al., 2010). Too often, 

these efforts are not linked with other organizational activities that focus on policy and decision-making 

related to outcomes accountability. A comprehensive audit, however, can help organizations identify the 

existing gaps between CLAS programming and initiatives and widespread organizational policies that can 

support, sustain, and ultimately improve such initiatives (Wynia et al., 2010).

Integrate CLAS-related measures into measurement and continuous quality improvement 

activities

Integrating measures related to cultural and linguistic competency into existing assessment efforts and 

continuous quality improvement programs helps organizations learn whether CLAS delivery processes are 

producing the desired results. Without incorporating such measures into assessment, planning, 

implementation, and evaluation efforts, organizations will not be able to demonstrate successfully the 

effectiveness of CLAS delivery, nor will they be able to identify ways to improve CLAS implementation.

CLAS-related measures in performance improvement and outcomes assessments include but are not 

limited to:

o Accessibility of interpreter services

o Effectiveness of cultural and linguistic competency training for providers and nonclinical staff

o Differences in the use of services among diverse populations
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o Impact of culturally and linguistically competent service provision on health outcomes and health 

status and on individuals’ satisfaction

Strategies for Implementation 

The following are possible implementation strategies for conducting organizational assessments:

o Conduct an organizational assessment or a cultural audit using existing cultural and linguistic 

competency assessment tools to inventory structural policies, procedures, and practices. These 

tools can provide guidance to determine whether the core structures and processes (e.g., 

management, governance, delivery systems, and customer relation functions) necessary for 

providing CLAS are in place.

o Use results from assessments to identify assets (e.g., bilingual staff members who could be used 

as interpreters, existing relationships with community-based ethnic organizations), weaknesses 

(e.g., no translated signage or cultural competency training), and opportunities to improve the 

organization’s structural framework and capacity to address cultural and linguistic competence in 

care (e.g., revise mission statement, recruit people from diverse cultures into policy and 

management positions).

o Following the assessment, prepare adequate plans for developing CLAS (see Standard 9). 

Subsequent ongoing assessment helps organizations to monitor their progress in implementing 

the enhanced National CLAS Standards and to refine their strategic plans.

The following are implementation strategies for integrating CLAS-related measures into measurement and 

continuous quality improvement activities (QSource, 2005):

o Implement ongoing organizational assessment of CLAS-related activities

o Provide individuals with CLAS-oriented feedback forms and include self-addressed, stamped 

envelopes to improve receipt of feedback

o Conduct focus groups with individuals to monitor progress and identify barriers to full-scale CLAS 

implementation

o Assess the standard of care provided for various chronic conditions to determine whether 

services are uniformly provided across cultural groups

o Add CLAS-related questions to staff orientation materials and yearly reviews

o Develop a system of reviewing and incorporating feedback and suggestions received and for 

monitoring their effect on CLAS implementation and outcomes
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o Identify outcome goals, including metrics, regarding cultural and linguistic competency and 

assess at regular intervals

Resources 

American Medical Association. (n.d.). Communication climate assessment toolkit. Retrieved from 

http://www.ama-assn.org/go/ccat

Beach, M. C., Cooper, L. A., Robinson, K. A., Price, E. G., Gary, T. L., Jenckes, M. W., ... Powe, N. R. 

(2004). Strategies for improving minority healthcare quality (AHRQ Publication No. 04-E008-02). 

Retrieved from Agency for Healthcare Research and Quality website: 

http://archive.ahrq.gov/downloads/pub/evidence/pdf/minqual/minqual.pdf 

Campinha-Bacote, J. (2002). Inventory for assessing the process of cultural competence among 

healthcare professionals-Revised (IAPCC-R). Retrieved from 

http://www.transculturalcare.net/iapcc-r.htm

Drucker, P. F. (1998). The Drucker Foundation self-assessment tool: Participant workbook. Hoboken, NJ: 

Jossey-Bass, Inc.

Hasnain-Wynia, R., & Baker, D. W. (2006). Obtaining data on patient race, ethnicity, and primary 

language in health care organizations: Current challenges and proposed solutions. Health 

Services Research, 41, 1501–1518. doi:10.1111/j.1475-6773.2006.00552.x

Johns Hopkins University. (2010). COA360. Retrieved from www.COA360.org

National Center for Cultural Competence, Georgetown University Center for Child and Human 

Development, Georgetown University Medical Center. (n.d.). Cultural competence health 

practitioner assessment (CCHPA). Retrieved from 

http://nccc.georgetown.edu/features/CCHPA.html

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2008). 

Hospital language services: Quality improvement and performance measures. In Advances in 

patient safety: New directions and alternative approaches, Volume 2. Culture and redesign

(AHRQ Publication No. 08-0034-2). Retrieved from http://www.ncbi.nih.gov/books/NBK43719 

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2011). 

Surveys on patient safety culture. Retrieved from http://www.ahrq.gov/qual/patientsafetyculture/

Vogt, K. (2006, September). Mystery shopping gaining popularity in health care sector: The rise of 

consumer-directed care is one reason why physicians, hospitals and health plans are sending 

people incognito to learn how things are working. American Medical News. Retrieved from 

http://www.ama-assn.org/amednews/2006/09/18/bise0918.htm
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Wang, S. (2006, August 8). Health care taps “mystery shoppers”: To improve service, hospitals and 

doctors hire spies to pose as patients and report back. Wall Street Journal. Retrieved from 

http://online.wsj.com/article/SB115499684792929340.html

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

Andrulis, D., Delbanco, T., Avakian, L., & Shaw-Taylor, Y. (2001). Conducting a cultural competence selfassessment. Retrieved from http://erc.msh.org/provider/andrulis.pdf

Briefer French, J., Schiff, D., Han, E., & Weinick, R. (2008). Multicultural health care: A quality 

improvement guide. Retrieved from National Committee for Quality Assurance website: 

http://www.ncqa.org/Portals/0/HEDISQM/CLAS/CLAS_toolkit.pdf

The Joint Commission. (2010). Advancing effective communication, cultural competence, and patientand family-centered care: A roadmap for hospitals. Retrieved from 

http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

QSource, Underserved Quality Improvement Organization Support Center. (2005). CLAS Standards 

implementation tips. Retrieved from 

http://www.qsource.org/uqiosc/CLAS%20Standards%20Strategies%5B7AUG-2005%5D.pdf

Rice, M. F. (2005). Teaching public administration education in the post modern era. In M. F. Rice (Ed.), 

Diversity and public administration: Theory, issues, and perspectives (pp. 87–103). Armonk, NY: 

Sharpe.

Rice, M. F. (2008). A primer for developing a public agency service ethos of cultural competency in public 

services programming and public services delivery. Journal of Public Affairs Education, 14, 21–38.

Wynia, M. K., Johnson, M., McCoy, T. P., Passmore Griffin, L., & Osborn, C. Y. (2010). Validation of an 

organizational communication climate assessment toolkit. American Journal of Medical Quality, 

25(6), 436–443. doi:10.1177/1062860610368428
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Standard 11: Collect and Maintain Demographic Data

Standard 11 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS 

on health equity and outcomes and to inform service delivery.

Purpose 

The purposes of collecting and maintaining demographic data are:

o To accurately identify population groups within a service area

o To monitor individual needs, access, utilization, quality of care, and outcome patterns

o To ensure equal allocation of organizational resources

o To improve service planning to enhance access and coordination of care

o To assess and improve to what extent health care services are provided equitably

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Collect and maintain accurate and reliable demographic data

Health and health care organizations should collect key data from individuals using personnel trained in 

cultural and linguistic competency. Data collected should include demographic information such as race, 

ethnicity, sex, language, and disability status (HHS, 2011ab). When elements of such data are collected 

in different ways across different sectors of the health and health care system and by separate 

organizations, the data are fragmented and often poorly integrated (IOM, 2009; National Research 

Council, 2009).

The availability of demographic data, particularly race and ethnicity, is the first step in being able to 

demonstrate the effectiveness of CLAS in the delivery of quality, equitable care and, ultimately, in 

reducing disparities (Hasnain-Wynia & Baker, 2006; Nerenz, 2005; HHS, 2011b). Other reasons to collect 

data pertaining to CLAS are (Massachusetts Department of Public Health, Office of Health Equity, 2009):
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o To meet state and federal reporting requirements, including new requirements being 

implemented under health reform

o To establish the foundation for cultural and linguistic competency

o To become more responsive to cultural preferences

o To tailor services to diverse needs

o To use resources more cost effectively

o To become more competitive in the market place

In organizations with multiple points of entry, information collected at one point should be routinely 

shared across other service sectors or departments consistent with the confidentiality requirements (see 

p119). Ideally, for programs requiring enrollment (e.g., managed care programs), the person responsible 

for enrollment would collect these data and then share the information with the provider. In other cases, 

health professionals, such as physicians or pharmacists, could collect and record this information at the 

first point of contact (Wynia, Ivey, & Hasnain-Wynia, 2010). The information should be included in the 

individual’s record and communicated to other departments that might have contact with the individual, 

such as billing or member services. The utilization of electronic health records and other health 

information technology (HIT) systems could significantly facilitate this sharing of data within and between 

organizations (IOM, 2009).

To ensure the accuracy and reliability of the data collected, organizations should facilitate processes that 

allow for self-identification and avoid use of observational/visual assessment methods, the latter of which 

is considered to be less reliable (Hasnain-Wynia & Baker, 2006; Hasnain-Wynia, Pierce, & Pittman, 2004; 

Higgins & Taylor, 2009). If a demographic variable (e.g., race) has more than one category, individuals 

should be allowed to indicate all categories that apply. In addition, with the increased adoption of health 

information technology, organizations have another way to improve upon the collection and exchange of 

reliable data (IOM, 2009).

In October 2011, the U.S. Department of Health and Human Services released implementation guidance 

for the collection of race, ethnicity, sex, primary language, and disability status data (HHS, 2011b). The 

purpose of the guidance was to promulgate a set of uniform data collection standards for inclusion in 

population-health surveys conducted or sponsored by HHS as required by Section 4302 of the Affordable 

Care Act.

In addition to the standards below, HHS is developing a national data progression plan on sexual 

orientation and gender identity variables. The Blueprint will be updated accordingly to reflect the most 

current HHS requirements.
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The HHS implementation guidance is clear in its intent that the data collection standards represent the 

minimum, not the maximum, requirements. The variables noted in the guidance are not intended to limit 

the collection of needed data. Agencies are encouraged to collect additional data as needed, as long as 

the minimum standard is included, the data can be aggregated up to the minimum standard (in the case 

of race and ethnicity), and the sample size supports those estimates. For the disability data standard, 

although survey questions and answer categories included in the standard cannot be changed, additional 

disability questions may be included.

HHS Data Collection Standards (HHS, 2011a)
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o Sex Data Standard

• What is your sex?

□ Male

□ Female

o Primary Language Data Standard

• How well do you speak English? (5 years old or older)

□ Very well

□ Well

□ Not well

□ Not at all

Recommended additional questions

• Do you speak a language other than English at home? (5 years old or older)

□ Yes

□ No

For persons speaking a language other than English (answering yes to the question above):

• What is this language? (5 years old or older)

□ Spanish

□ Other Language (Identify)

o Disability Status Data Standard

• Are you deaf or do you have serious difficulty hearing?

□ Yes

□ No

• Are you blind or do you have serious difficult seeing, even when wearing glasses?

□ Yes

□ No

• Because of a physical, mental, or emotional condition, do you have serious difficulty 

concentrating, remembering, or making decisions? (5 years old or older)

□ Yes

□ No

• Do you have serious difficulty walking or climbing stairs? (5 years old or older)

□ Yes

□ No

• Do you have difficulty dressing or bathing? (5 years old or older)

□ Yes

□ No
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• Because of a physical, mental, or emotional condition, do you have difficulty doing 

errands alone, such as visiting a doctor’s office or shopping? (15 years old or older)

□ Yes

□ No

To monitor and evaluate the impact of CLAS on health equity and outcomes and to inform 

service delivery

Ultimately, one purpose of collecting and maintaining accurate demographic data is to utilize the data in 

organizational monitoring, evaluation, and continuous quality improvement activities (IOM, 2009; Wynia 

et al., 2010). In addition, while the assessment of health disparities and inequities is complex and entails 

linking demographic data with other types of data (e.g., service data, quality of care data), the availability 

of accurate and reliable demographic data is key in documenting such issues and developing strategies to 

address them (Bilheimer & Klein, 2010; Hasnain-Wynia & Baker, 2006; IOM, 2009; Lurie & Fremont, 

2006).

Organizations may use demographic data to determine basic information about trends in organizational 

and health care utilization, such as the total number of visits made to emergency departments based on 

race/ethnicity and gender or the total number of individuals requesting language assistance. This 

information could then be used to make staffing assignment decisions or determine the need for 

additional language assistance resources. When linked with other data, health and health care 

organizations can make increased data-informed decisions and improve the quality of care, consistent 

with quality improvement activities (Fiscella, 2011). For example, in response to changing state 

regulations on the collection of race/ethnicity/language data, several hospitals in Massachusetts began 

linking these data with performance and quality measures to identify disparities in health and health care, 

develop targeted programs for employees concerning cultural competency, and develop targeted 

interventions to engage individuals from specific populations (Jorgensen, Thorlby, Weinick, & Ayanian, 

2010).

Current surveys and data collection tools may not encompass all demographic groups in a particular area 

or region. For example, although lesbian, gay, bisexual and transgender related data have been collected 

on several surveys in the past, there are a number of challenges (HHS, 2012). This can limit the ability to 

estimate population size and address health needs. Organizations should sensitively and strategically 

utilize, and develop if necessary, survey instruments that will encompass the various demographic groups 

in their community. Partnerships, as described in Standard 13, can assist in the identification and 

development of such instruments.
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Confidentiality Issues

In collecting data, organizations will likely encounter issues related to confidentiality. Many individuals 

may be hesitant to provide personal information, such as race, ethnicity, and language, due to concerns 

about privacy or fear of negative reprisals (IOM, 2009; Robert Wood Johnson Foundation, 2004). 

Individuals may believe that they will receive disparate services based on their answers to questions 

about race, ethnicity, primary language, gender identity, or sexual orientation in a health or service 

encounter. Still others may worry about being asked to pay higher insurance premiums based on race, 

ethnicity, or would either say medical condition or pre-existing condition.

Data collection should not be at the detriment of the relationship between the individual and the health 

care or service provider, and the individual should not be put at risk to collect such data. Just as 

important is the organization’s obligation to inform individuals and, ideally, all groups in the community 

about the purpose of collecting such data, the intended uses of the data, and the individual’s right to 

withhold the data. Individuals need to be assured that the information is being gathered for legitimate 

purposes, and they should be notified as to the circumstances in which their data will be shared (AHRQ, 

2011; Lurie & Fremont, 2006). In addition to following ethical principles and standards, health care 

organizations should follow the federal regulation concerning the privacy of health information. The 

Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 requires health care 

organizations and providers to collect, use, and/or disclose individually identifiable data and information 

only to the extent necessary to accomplish a specific purpose and to obtain consent for both routine and 

nonroutine use and disclosure of health records. The regulation also calls for organizations and providers 

to provide a clear, written explanation of how health information can and will be used, kept, and 

disclosed (HHS ODPHP, 2000).

To maintain the confidentiality and privacy of potentially identifiable data, there are a number of options 

organizations and providers could choose. For example, organizations and providers could de-identify the 

data or use codes for data, such as race and ethnicity information, that would not be linked to individuals’ 

names. These de-identified data could then be analyzed and reported in aggregate to monitor disparities 

and measure outcomes. In addition, organizations could clarify the purpose of the data to staff and 

specify which staff members may have access to the data. In establishing and enforcing data collection 

and access policies and procedures, organizations should also ensure that all staff members with data 

access regularly receive training on client record confidentiality (HHS OMH, 2001).

Strategies for Implementation 

The following are possible implementation strategies for collecting and maintaining demographic data:
National Standards for CLAS in Health and Health Care:

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Table 4: A Process for Collecting Data

When? Ask for data early — ideally, during admission or registration

Who? Properly trained admissions or reception staff could collect data

What will you tell 

individuals?

Before obtaining information, develop a script to communicate that:

o This information is important.

o It will be used to improve care and services and to prevent 

discrimination.

o This information will be kept confidential.

In addition, address any concerns up front and clearly.

How? Individual self-report — select their own race, ethnicity, language, etc.

What information 

will you collect? 

(Individual Data)

o Race

o Ethnicity

o Nationality

o Nativity

o Ability to speak English

o Language(s) other than English spoken

o Preferred spoken/written languages or other mode of communication

o Age

o Gender

o Sexual orientation

o Gender identity

o Income

o Education

o Informed of right to interpreter services

o Request for, and/or use of, interpreter services

o Treatment history

o Medical history

o Outcome data (service type, utilization, length of stay)

o Client satisfaction

See also aforementioned HHS Data Collection Standards

What information 

will you collect? 

(Staff Data)

o Race

o Ethnicity

o Nationality

o Nativity

o Primary/preferred language

o Gender

o Records of cultural and linguistic competency training participation and 

evaluations

Tools to collect 

and store data

Use standard collection instruments. Store data in a standard electronic format.
National Standards for CLAS in Health and Health Care:

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Training Provide ongoing data training and evaluation to staff

(Massachusetts Department of Public Health, Office of Health Equity, 2009) 

Adapted from the Health Research and Evaluation Trust Health Disparities Toolkit (Hasnain-Wynia et al., 2007) 

Resources 

Asset-Based Community Development Institute. (2009). Retrieved from http://www.abcdinstitute.org/

Baker, Q. E., Davis, D. A., Gallerani, R., Sanchez, V., Viadro, C., & The Center for the Advancement of 

Community Based Public Health. (2000). An evaluation framework for community health 

programs. Retrieved from 

http://www.doh.state.fl.us/COMPASS/documents/Community_Health_Programs_Eval.pdf

Hasnain-Wynia, R., Van Dyke, K., Youdelman, M., Krautkramer, C., Ivey, S., Gilchick, R., Kaleba, E., & 

Wynia, M. K. (2010). Barriers to collecting patient race, ethnicity and primary language data in 

physician practices: An exploratory study. Journal of the National Medical Association, 102(9), 

769–775.

Sharpe, P. A., Greaney, M. L., Lee, P. R., & Royce, S. W. (2000). Assets-oriented community assessment. 

Public Health Reports, 115, 205–211. Retrieved from 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308712/pdf/pubhealthrep00022-0103.pdf

U.S. Department of Commerce, Census Bureau. (n.d.). American factfinder. Retrieved from 

http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2011). 

CAHPS cultural competence item set. Retrieved from https://www.cahps.ahrq.gov/surveysguidance/item-sets/cultural-competence.aspx

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2011). 

CAHPS item set for addressing health literacy. Retrieved from 

https://www.cahps.ahrq.gov/surveys-guidance/item-sets/health-literacy.aspx

U.S. Department of Health and Human Services, Office of Minority Health. (2011). Final data collection 

standards for race, ethnicity, primary language, sex, and disability status required by Section 

4302 of the Affordable Care Act. Retrieved from 

http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=208

U.S. Department of Health and Human Services. (2011). Improving data for the LGBT community.

Retrieved from http://www.healthcare.gov/news/factsheets/2011/06/lgbt06292011a.html

Wynia, M., Hasnain-Wynia, R., Hotze, T. D., & Ivey, S. L. (2011). Collecting and using race, ethnicity and 

language data in ambulatory settings: A white paper with recommendations from the 

Commission to End Health Care Disparities. Retrieved from American Medical Association 

website: http://www.ama-assn.org/resources/doc/public-health/cehcd-redata.pdf
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Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

Bilheimer, L. T., & Klein, R. J. (2010). Data and measurement issues in the analysis of health disparities. 

Health Services Research, 45, 1489–1507. doi:10.1111/j.1475-6773.2010.01143.x

Fiscella, K. (2011). Eliminating disparities in health care through quality improvement. In R. A. Williams 

(Ed.), Healthcare disparities at the crossroads with healthcare reform (pp. 231–267). New York, 

NY: Springer.

Hasnain-Wynia, R., & Baker, D. W. (2006). Obtaining data on patient race, ethnicity, and primary 

language in health care organizations: Current challenges and proposed solutions. Health 

Services Research, 41, 1501–1518. doi:10.1111/j.1475-6773.2006.00552.x

Hasnain-Wynia, R., Pierce, D., Haque, A., Hedges Greising, C., Prince, V., & Reiter, J. (2007). Health 

Research and Educational Trust disparities toolkit. Retrieved from http://www.hretdisparities.org/

Hasnain-Wynia, R., Pierce, D., & Pittman, M. A. (2004). Who, when, and how: The current state of race, 

ethnicity, and primary language data collection in hospitals (Commonwealth Fund Publication No. 

726). Retrieved from The Commonwealth Fund website: 

http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2004/May/Who

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0Ethnicity%20%20and%20Primary%20Language%20Data%20Collection%20in%20Ho/hasnain

%20wynia_whowhenhow_726%20pdf.pdf

Higgins, P. C., & Taylor, E. F. (2009). Measuring racial and ethnic disparities in health care: Efforts to 

improve data collection. Retrieved from Mathematica Policy Research website: 

http://www.mathematica-mpr.com/pdfs/health/DisparitiesHealthcare.pdf

Institute of Medicine. (2009). Race, ethnicity, and language data: Standardization for health care quality 

improvement. Retrieved from http://iom.edu/Reports/2009/RaceEthnicityData.aspx

Jorgensen, S., Thorlby, R., Weinick, R. M., & Ayanian, J. Z. (2010). Responses of Massachusetts hospitals 

to a state mandate to collect race, ethnicity and language data from patients: A qualitative study. 

BMC Health Services Research, 10, 352–359. doi:10.1186/1472-6963-10-352

Lurie, N., & Fremont, A. (2006). Looking forward: Cross-cutting issues in the collection and use of 

racial/ethnic data. Health Services Research, 41, 1519–1533. doi:10.1111/j.1475-

6773.2006.00553.x

Massachusetts Department of Public Health, Office of Health Equity. (2009). Making CLAS happen: Six 

areas for action. Retrieved from http://www.mass.gov/eohhs/provider/guidelinesresources/services-planning/workforce-development/health-equity/clas/making-clas-happen.html
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A Blueprint for Advancing and Sustaining CLAS Policy and Practice

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National Research Council. (2009). Principles and practices for a federal statistical agency (4th ed.). 

Retrieved from http://www.nap.edu/catalog.php?record_id=12564

Nerenz, D. R. (2005). Health care organizations’ use of race/ethnicity data to address quality disparities. 

Health Affairs, 24, 409–416. doi:10.1377/hlthaff.24.2.409.

Robert Wood Johnson Foundation. (2004). Key findings from a national survey conducted among adults 

who have health care coverage on behalf of the Robert Wood Johnson Foundation on the issue 

of disparities in health care. Retrieved from 

http://www.rwjf.org/files/newsroom/POSfullMemo.pdf

U.S. Department of Health and Human Services. (2011a). Implementation guidance on data collection 

standards for race, ethnicity, sex, primary language, and disability status. Retrieved from 

http://aspe.hhs.gov/datacncl/standards/ACA/4302/index.pdf

U.S. Department of Health and Human Services. (2011b). HHS action plan to reduce racial and ethnic 

disparities: A nation free of disparities in health and health care. Retrieved from 

http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf

U.S. Department of Health and Human Services. (2012). Lesbian, gay, bisexual, and transgender health. 

Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2011). 

New communication protocols, inclusive policies, and ongoing training lead to culturally 

competent care for lesbian, gay, bisexual, and transgender patients. Retrieved from 

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U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 

(2000). Healthy people 2010: Understanding and improving health. Retrieved from 

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U.S. Department of Health and Human Services, Office of Minority Health. (2001). National standards for 

culturally and linguistically appropriate services in health care: Final report. Retrieved from 

http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf

Wynia, M. K., Ivey, S. L., & Hasnain-Wynia, R. (2010). Collection of data on patients' race and ethnic 

group by physician practices. New England Journal of Medicine, 362, 846–850.
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Standard 12: Conduct Assessments of Community Health Assets 

and Needs

Standard 12 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Conduct regular assessments of community health assets and needs and use the results to plan and 

implement services that respond to the cultural and linguistic diversity of populations in the service area.

Purpose 

The purposes of conducting assessments of community health assets and needs are:

o To determine the service assets and needs of the populations in the service areas (needs 

assessment)

o To identify all of the services available and not available to the populations in the service areas 

(resource inventory and gaps analysis)

o To determine what services to provide and how to implement them, based on the results of the 

community assessment

o To ensure that health and health care organizations obtain demographic, cultural, linguistic, and 

epidemiological baseline data (quantitative and qualitative) and update the data regularly to 

better understand the populations in their service areas

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Conduct Regular Assessments of Community Health Assets and Needs

An effective model for knowing and understanding one’s community and how best to serve it is a 

community services assessment.

A community services assessment is composed of three parts (AED Center on AIDS & Community Health, 

2005):

o Needs Assessment
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o Resource Inventory

o Gaps Analysis

Community services assessments are currently used in various areas of public and community health, 

including AIDS prevention (HHS CDC, 2003). The cultural knowledge they provide can help organizations 

better utilize community assets and develop or adapt existing services to better meet community needs. 

A community services assessment helps an organization understand its community by identifying 

individuals from the populations in the service area who may need specific, tailored interventions due to 

cultural or linguistic differences. A community services assessment may also aid in the development of 

culturally and linguistically appropriate services by helping to identify and define the dynamics of 

difference between organizations and the populations they serve, especially those involving health 

beliefs, attitudes toward health and health care, and perceptions of effective health communication. It 

also allows an organization to avoid duplication in the creation or promotion of services via identification 

of the assets already utilized in the community. These data can be used for the development or 

adaptation of services to address unmet needs (e.g., incorporating assets in the development or 

adaptation of services) and to provide a framework within which services can be evaluated.

Once key stakeholders from the populations in the service area are identified, an organization will be 

better able to establish partnerships with community-based organizations, faith-based organizations, and 

nonprofit or nongovernmental organizations within the service area. These partnerships will not only 

improve access to and utilization of services through improved awareness, but they may also increase an 

individual’s perceived satisfaction with those services. Community support and insight facilitate the 

implementation of culturally and linguistically appropriate services and policies.

Plan and implement services that respond to the cultural and linguistic diversity of 

populations in the service area

Conducting a community needs assessment should be just the first step in a comprehensive effort to 

engage local communities in organizational planning and operations (see Standard 13). Data and 

information collected from regular community assessments can be used to develop a comprehensive 

profile of the populations in the service area, which could have significant demographic and 

epidemiological value. Such a profile would help organizations, providers, and policymakers develop 

appropriate services and evaluate access to and utilization of those services over time. In addition, data 

from this profile could be used to generate more specific profiles (e.g., linguistic or geographic profiles) 

that could be used to inform targeted service development and service delivery plans.

According to The Joint Commission’s Advancing Effective Communication, Cultural Competence, and 

Patient- and Family-Centered Care: A Roadmap for Hospitals (2010), health and health care organizations 

should develop and maintain community profiles to:
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o Allow organizations to plan for the services necessary to meet individuals’ and groups’ needs

o Identify and respond to changes in the demographics of the surrounding community

o Identify potential disparities in care or services

o Plan for services to meet unique individual needs

o Identify language needs of the population

o Provide appropriate language services to meet those needs

Strategies for Implementation 

The following are possible implementation strategies for assessing community health assets and needs.

o Partner with other organizations to negotiate a data sharing agreement, which could facilitate the 

linking of different types of data.

o Collaborate with other organizations and stakeholders in data collection, analysis, and reporting 

efforts to increase data reliability and validity.

o Conduct focus groups with individuals in the community (QSource, 2005).

o Review demographic data collected with local health and health care organizations (QSource, 

2005).

o Use multiple sources in the community to collect data, including faith-based organizations, social 

workers, and managed care organizations (QSource, 2005).

The HHS Administration for Children and Families’ Head Start initiative recommends the following Outline 

for Assessing Community Needs and Resources (HHS Administration for Children and Families, 2008; 

University of Kansas, n.d.):

1. Describe the makeup and history of the community to provide a context within which to collect 

data on its current concerns.

a. Comment on the types of information that best describe the community (e.g., 

demographic, historical, political, civic participation, key leaders, past concerns, 

geographic, assets)

b. Describe the sources of information used (e.g., public records, local people, Internet, 

maps, phone book, library, newspaper)

c. Comment on whether there are sufficient resources available to collect this information 

(e.g., time, personnel, resources)
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d. Describe the methods used to collect descriptive information (e.g., public forums,

listening sessions, focus groups, interviews, surveys, observation)

e. Assess the quality of the information

f. Describe the strengths and difficulties identified

2. Describe what matters to people in the community, including a description of:

a. Issues that people in the community care about (e.g., safety, education, housing, health)

b. How important these issues are to the community (e.g., perceived importance, 

consequences for the community)

c. Methods the organization will (did) use to listen to the community (e.g., listening 

sessions, public forums, interviews, concerns surveys, focus groups)

3. Describe what matters to key stakeholders, including:

a. Who else cares about the issue (the stakeholders) and what they care about

b. What stakeholders want to know about the situation (e.g., who is affected, how many, 

what factors contribute to the problem)

c. Prioritized populations and subgroups to whom stakeholders are targeting benefits

d. Methods used to gather information (e.g., surveys, interviews)

4. (For each identified problem/goal) Describe the evidence indicating whether the problem/goal 

should be a priority issue, including:

a. The community-level indicators related to the issue (e.g., rate of infant deaths or vehicle 

crashes)

b. How frequently the problem (or related behavior) occurs (e.g., number of youth 

reporting alcohol use in the past 30 days)

c. How many people are affected by the problem and the severity of its effects

d. How feasible it is to address the issue

e. Possible impact and/or consequences of addressing the problem/goal

5. Describe the barriers and resources for addressing the identified issue(s), including:

a. Barriers or resistance to solving the problem or achieving the goal (e.g., denial or 

discounting of the problem) and how they can be minimized (e.g., reframing the issue)

b. What resources and assets are available and how the organization can tap into those 

resources to address the issue

c. Community context or situation that might make it easier or more difficult to address this 

issue

6. (Based on the assessment) Select and state the priority issue (or issues) to be addressed by the 

organization.
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Resources 

Asset-Based Community Development Institute. (2009). Retrieved from http://www.abcdinstitute.org/

Aubel, J. (1999). Participatory program evaluation manual: Involving program stakeholders in the 

evaluation process. Retrieved from http://www.idrc.ca/uploads/userS/10504133390Participatory_Program_Evaluation_Manual.pdf

Baker, Q. E., Davis, D. A., Gallerani, R., Sanchez, V., Viadro, C., & The Center for the Advancement of 

Community Based Public Health. (2000). An evaluation framework for community health 

programs. Retrieved from 

http://www.doh.state.fl.us/COMPASS/documents/Community_Health_Programs_Eval.pdf

Clinical and Translational Science Awards Consortium, Community Engagement Key Function Committee 

Task Force on the Principles of Community Engagement. (2011). Principles of community 

engagement (2nd ed.) (National Institutes of Health Publication No. 11-7782). Retrieved from 

http://www.atsdr.cdc.gov/communityengagement/pdf/PCE_Report_508_FINAL.pdf

Sharpe, P. A., Greaney, M. L., Lee, P. R., & Royce, S. W. (2000). Assets-oriented community assessment. 

Public Health Reports, 115, 205–211. Retrieved from 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308712/pdf/pubhealthrep00022-0103.pdf

University of Washington, Community-Campus Partnerships for Health. (n.d.). Community-based 

participatory research. Retrieved from http://depts.washington.edu/ccph/commbas.html

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

AED Center on AIDS & Community Health. (2005). HIV prevention community planning: An orientation 

guide. Retrieved from 

http://www.cdc.gov/hiv/topics/cba/resources/guidelines/Orientation_Final.pdf 

The Joint Commission. (2010). Advancing effective communication, cultural competence, and patientand family-centered care: A roadmap for hospitals. Retrieved from 

http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

QSource, Underserved Quality Improvement Organization Support Center. (2005). CLAS Standards 

implementation tips. Retrieved from 

http://www.qsource.org/uqiosc/CLAS%20Standards%20Strategies%5B7AUG-2005%5D.pdf

University of Kansas. (n.d.). Assessing community needs and resources: Outline for assessing community 

needs and resources. Retrieved from 

http://ctb.ku.edu/en/dothework/tools_tk_content_page_77.aspx
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U.S. Department of Health and Human Services, Administration for Children and Families. (2008). Outline 

for assessing community needs and resources: Assessing community needs and resources. 

Retrieved from http://eclkc.ohs.acf.hhs.gov/hslc/ttasystem/operations/Fiscal/Grants/Community%20Assessment/fiscal_art_00177_090205.html 

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. (2003). HIV 

prevention: Community planning guide. Retrieved from http://www.cdc.gov/hiv/pubs/hiv-cp.pdf
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Standard 13: Partner with the Community

Standard 13 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Partner with the community to design, implement, and evaluate policies, practices, and services to ensure 

cultural and linguistic appropriateness.

Purpose 

The purpose of partnering with the community is:

o To provide responsive and appropriate service delivery to a community

o To ensure that services are informed and guided by community interests, expertise, and needs

o To increase use of services by engaging individuals and groups in the community in the design 

and improvement of services to meet their needs and desires

o To create an organizational culture that leads to more responsive, efficient, and effective services 

and accountability to the community

o To empower members of the community in becoming active participants in the health and health 

care process

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Partner with the community

Community partnerships are an essential component in the provision of cultural and linguistic 

competency. Only through meaningful community partnerships can an organization truly understand the 

individual needs of the diverse population it serves, appropriately allocate resources, and develop an 

accountable system that provides equitable culturally and linguistically appropriate care and services 

(Douglas et al., 2009; Wu & Martinez, 2006). In addition, community engagement has been found to be 

strongly correlated with higher patient-reported quality of care and trust (Wynia et al., 2010).
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Design, implement, and evaluate policies, practices, and services to ensure cultural and 

linguistic appropriateness

Input from individuals in the community is essential to planning, implementing, and improving services. 

Community input provides health and health care organizations with the opportunity to learn about and 

understand their reputation in the community. Designing, implementing, and evaluating services, all of 

which have been informed by community input, is particularly useful in improving the organization’s reach 

and services. If an organization communicates messages that individuals in the community view as 

unrealistic — for example, advice to take a daily walk when there are concerns about neighborhood 

safety — the messages may not result in the desired behavior change and will be unproductive. 

Organizations will be more effective and will ultimately experience cost savings if they consider 

community input.

Strategies for Implementation 

The following are implementation strategies for partnering with the community:

o Partner with local culturally diverse media to promote better understanding of available care and 

services and of appropriate routes for accessing services among all community members (WilsonStronks & Galvez, 2007).

o Build coalitions with community partners to increase reach and impact in identifying and creating 

solutions. For example:

• Work on joint steering committees and coalitions.

• Sponsor or participate in health fairs, cultural festivals, and celebrations.

• Offer education and training opportunities.

o Convene town hall meetings, hold community forums, and/or conduct focus groups (Prevention 

by Design, 2006).

o Develop opportunities for capacity building initiatives, action research, involvement in service 

development, and other activities to empower the community (Equality and Human Rights 

Commission, 2009).

o Collaborate to reach more people, to share information and learn, and to improve services. Work 

with partners to advertise job openings, identify interpreting resources, and organize health 

promotion activities. Successful partnerships benefit all.

In addition, the following professionals and volunteers may facilitate communication between an 

organization and the community it serves:
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o Cultural brokers are individuals from the community who can serve as a bridge between an 

organization and people of different cultural backgrounds. Cultural brokers should be familiar 

with the health system and with the community in which they live and/or from where they 

originated. They can become a valuable source of cultural information and serve as mediators in 

conflicts and as agents for change (Massachusetts Department of Public Health, 2009).

o Promotores de salud/community health workers are volunteer community members and paid 

front-line public health workers who are trusted members of the community served or have an 

unusually close understanding of that community. They generally share the ethnicity, language, 

socio-economic status, and life experiences of the community members. These social attributes 

and trusting relationships enable community health workers to serve as liaisons, links, or 

intermediaries between health and social services and the community to facilitate access to and 

enrollment in services and improve the quality and cultural competency of services (HHS OMH, 

2011).

Resources 

Association of the Bar of the City of New York. (n.d.). Diversity committees that make a difference.

Retrieved from 

http://www.akcsystems.com/test3/images/stories/pdfs/Diversity%20Committee%20Notes%20Art

icle10_2004.pdf

Baker, S., Conrad, D., Béchamps, M., & Barry M. (2002). Healthy people toolkit 2010: A field guide to 

health planning. Retrieved from Public Health Foundation website: 

http://www.phf.org/resourcestools/Documents/HP2010Toolkit2002.pdf

Clinical and Translational Science Awards Consortium, Community Engagement Key Function Committee 

Task Force on the Principles of Community Engagement. (2011). Principles of community 

engagement (2nd ed.) (National Institutes of Health Publication No. 11-7782). Retrieved from 

http://www.atsdr.cdc.gov/communityengagement/pdf/PCE_Report_508_FINAL.pdf

Institute for Patient- and Family-Centered Care. (2011). Tools to foster the collaboration with patient and 

family advisors. Retrieved from http://www.ipfcc.org/tools/downloads-tools.html

Leonhardt, K., Bonin, D., & Pagel, P. (2008). Guide for developing a community-based patient safety 

advisory council (AHRQ Publication No. 08-0048). Retrieved from 

http://www.ahrq.gov/qual/advisorycouncil/advisorycouncil.pdf

Schillinger, D. (2010). An introduction to effectiveness, dissemination and implementation research: A 

resource manual for community-engaged research. Retrieved from 

http://accelerate.ucsf.edu/files/CE/edi_introguide.pdf
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Summit Health Institute for Research and Education. (2004). Building coalitions among communities of 

color: A multicultural approach. Retrieved from http://www.shireinc.org/wpcontent/files/Building_Coalitions_among_Communities_of_Color.pdf

Torres, G., & Margolin, F. (2003). The collaboration primer: Proven strategies, considerations, and tools 

to get you started. Retrieved from Health Research and Educational Trust website: 

http://www.hret.org/upload/resources/collaboration-primer.pdf

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2011). 

CAHPS cultural competence item set. Retrieved from https://www.cahps.ahrq.gov/surveysguidance/item-sets/cultural-competence.aspx

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

Douglas, M. K., Pierce, J. U., Rosenkoetter, M., Callister, L. C., Hattar-Pollara, M., Lauderdale, J., & 

Pacquiao, D. (2009). Standards of practice for culturally competent nursing care: A request for 

comments. Journal of Transcultural Nursing, 20, 257–269.

Equality and Human Rights Commission. (2009). Good practice in community engagement from an 

equality perspective. Retrieved from 

http://www.equalityhumanrights.com/uploaded_files/good_practice_in_community_engagement.

pdf 

Massachusetts Department of Public Health, Office of Health Equity. (2009). Making CLAS happen: Six 

areas for action. Retrieved from http://www.mass.gov/eohhs/provider/guidelinesresources/services-planning/workforce-development/health-equity/clas/making-clas-happen.html

Prevention by Design. (2006). Community engagement strategies: Tip sheet. Retrieved from 

http://socrates.berkeley.edu/~pbd/pdfs/Community_Engagement_Strategies.pdf 

U.S. Department of Health and Human Services, Office of Minority Health. (2011). Definition of 

promotoras de salud. Retrieved from 

http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlid=207&ID=8930 

Wilson-Stronks, A., & Galvez, E. (2007). Hospitals, language, and culture: A snapshot of the nation.

Retrieved from The Joint Commission website: 

http://www.jointcommission.org/assets/1/6/hlc_paper.pdf

Wu, E., & Martinez, M. (2006). Taking cultural competency from theory to action (Commonwealth Fund 

Publication No. 964). Retrieved from The Commonwealth Fund website: 

http://www.commonwealthfund.org/usr_doc/Wu_takingcultcomptheoryaction_964.pdf
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Wynia, M. K., Johnson, M., McCoy, T. P., Passmore Griffin, L., & Osborn, C. Y. (2010). Validation of an 

organizational communication climate assessment toolkit. American Journal of Medical Quality, 

25(6), 436–443. doi:10.1177/1062860610368428
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Standard 14: Create Conflict and Grievance Resolution Processes

Standard 14 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Create conflict and grievance resolution processes that are culturally and linguistically appropriate to 

identify, prevent, and resolve conflicts or complaints.

Purpose 

The purposes of creating conflict and grievance resolution processes that are culturally and linguistically 

appropriate are:

o To facilitate open and transparent two-way communication and feedback mechanisms between 

individuals and organizations

o To anticipate, identify, and respond to cross-cultural needs

o To meet federal and/or state level regulations that address topics such as grievance procedures, 

the use of ombudspersons, and discrimination policies and procedures

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Create conflict and grievance resolution processes that are culturally and linguistically 

appropriate

As documented in the HHS Agency for Healthcare Research and Quality’s 2011 National Healthcare 

Quality Report and National Healthcare Disparities Report, access to quality health care remains 

suboptimal, particularly for minority and low-income groups (2012). One contributing factor of health 

disparities is the existence of discriminatory, inequitable practice (IOM, 2003). Culturally and linguistically 

appropriate conflict and grievance resolution processes address the discrimination and unfair treatment 

— actual and perceived — of diverse populations. Discrimination based on race, ethnicity, sex, age, 

socioeconomic status, sexual orientation, gender identity, and other characteristics impede the provision 

of quality care and services, making culturally and linguistically competent conflict prevention and 

resolution a vital part of advancing health equity.
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Individuals from diverse backgrounds may encounter situations in which their needs and preferences are 

not accommodated or respected by the organization or its staff. These situations may range from 

differences related to informed consent and advance directives, to difficulty in accessing services or 

denial of services, to discriminatory treatment (HHS OMH, 2001). While personal preferences for care 

should be accommodated as much as possible and equitable nondiscriminatory treatment should be 

guaranteed, it is inevitable that individuals will have conflicts and grievances. To address this, 

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

conflicts and must develop a method through which individuals can provide feedback. All individuals must 

then be informed about, and have access to, these feedback procedures that cover all aspects of their 

interaction with the organization (HHS OMH, 2001).

Organizations should anticipate and be responsive to the differences that arise between individuals and 

the organization and its staff. This responsiveness may be achieved by integrating principles of cultural 

sensitivity into existing feedback procedures, as well as into policies, programs, and committees charged 

with responsibility for patient relations and legal or ethical issues. When existing structures are 

inadequate, new approaches may need to be developed.

As addressed in Standard 4, governance, leadership, and staff should be trained in cultural and linguistic 

competency so that they are prepared to respond appropriately to feedback received by individuals or 

groups in their service area. Procedural guidelines, courses, and case study analysis can educate staff on 

how to listen and respond respectfully. Appropriate training and procedural guidelines will allow staff to 

respond to all feedback, including complaints. Organizations should also create programs with an 

ombudsperson and a diverse staff to proactively address individuals’ rights and protections. Such a 

program can provide another quality feedback loop on the effectiveness of ongoing cultural and linguistic 

competency initiatives. The feedback process should be understandable, easily accessible, confidential, 

and transparent.

Health and health care organizations should not assume that a lack of conflict or complaints equates to 

satisfaction with services or care provided. Individuals may have fears or cultural beliefs that inhibit 

criticism or may not know that they have the right to provide feedback. Individuals may also believe that 

feedback will be disregarded by the organization. Thus, in anticipation of individuals who are not 

comfortable with expressing or acting upon their own concerns, the organization should have both formal 

and informal procedures to solicit feedback.

Strategies for Implementation 

The following are possible implementation strategies for creating conflict and grievance resolution 

processes that are culturally and linguistically appropriate:
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o Provide cross-cultural communication training, including how to work with an interpreter, and 

conflict resolution training to staff who handle conflicts, complaints, and feedback.

o Provide notice in signage, translated materials, and other media about the right of each individual 

to provide feedback, including the right to file a complaint or grievance.

o Develop a clear process to address instances of conflict and grievance that includes follow-up and 

ensures that the individual is contacted with a resolution and next steps (QSource, 2005).

o Obtain feedback via focus groups, community council or town hall meetings, meetings with 

community leaders, suggestion and comment systems, open houses, and/or listening sessions.

o Hire patient advocates or ombudspersons (QSource, 2005).

o Include oversight of conflict and grievance resolution processes to ensure their cultural and 

linguistic appropriateness as part of the organization’s overall quality assurance program.

Resources 

Dator, J. (1991). Culturally-appropriate dispute resolution techniques and the formal judicial system in 

Hawaii. A report to the State Justice Institute. Retrieved from 

http://www.futures.hawaii.edu/publications/courts/CultAppropAD1991.pdf

DuPraw, M., & Axner, M. (1997). Working on common cross-cultural communication challenges. 

Retrieved from http://www.pbs.org/ampu/crosscult.html

Lahey Clinic Foundation. (2012). Retrieved from http://www.lahey.org/

LeBaron, M. (1998). Mediation and multicultural reality. Retrieved from 

http://www.gmu.edu/programs/icar/pcs/lebaron.htm

Mind Tools. (n.d.). Conflict resolution: Resolving conflict rationally and effectively. Retrieved from 

http://www.mindtools.com/pages/article/newLDR_81.htm

National Center for Cultural Competence, Georgetown University Center for Child and Human 

Development, Georgetown University Medical Center. (2004). Bridging the cultural divide in 

health care setting: The essential role of cultural broker programs. Retrieved from 

http://gucchd.georgetown.edu/products/CulturalBrokerGuide_English.pdf

Rogers, S., & Vilhena, B. (2005). Benchmarking patient complaints data across Ontario hospitals: 

University Health Network invites collaboration [Online case study]. Healthcare Quarterly, 8, 82–

84. Retrieved from http://www.longwoods.com/product/download/code/17728

San Francisco Department of Public Health. (n.d.). Retrieved from http://www.sfdph.org/dph/default.asp
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Townsend, J. R. (2011). Creating a culturally and politically appropriate dispute resolution model: 

Working in Indian country. RCAC's Rural Review, 28(3), 1–7. Retrieved from 

http://www.rcac.org/assets/white-papers/CreatingACulturally.pdf

University of Colorado Conflict Information Consortium. (n.d.). Retrieved from 

http://conflict.colorado.edu/

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care.

Retrieved from http://www.nap.edu/openbook.php?record_id=10260&page=R1

QSource, Underserved Quality Improvement Organization Support Center. (2005). CLAS Standards 

implementation tips. Retrieved from 

http://www.qsource.org/uqiosc/CLAS%20Standards%20Strategies%5B7AUG-2005%5D.pdf

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2012). 

2011 national healthcare disparities report (AHRQ Publication No. 12-0006). Retrieved from 

http://www.ahrq.gov/qual/measurix.htm#quality 

U.S. Department of Health and Human Services, Office of Minority Health. (2001). National standards for 

culturally and linguistically appropriate services in health care: Final report. Retrieved from 

http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf
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Standard 15: Communicate the Organization’s Progress in 

Implementing and Sustaining CLAS

Standard 15 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate 

health care disparities by establishing a blueprint for health and health care organizations to:

Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, 

constituents, and the general public.

Purpose 

The purposes of communicating the organization’s progress in implementing and sustaining CLAS to all 

stakeholders, constituents, and the general public are:

o To convey information to intended audiences about efforts and accomplishments in meeting the 

National CLAS Standards

o To learn from other organizations about new ideas and successful approaches to implementing 

the National CLAS Standards

o To build and sustain communication on CLAS priorities and foster trust between the community 

and the service setting

o To meet community benefits and other reporting requirements, including accountability for 

meeting health care objectives in addressing the needs of diverse individuals or groups

Please refer to the glossary in Appendix A for definitions of the key terms used.

Components of the Standard 

Communicate the organization’s progress in implementing and sustaining CLAS

Communicating to all stakeholders, constituents, and the general public an organization’s efforts to 

implement and sustain the National CLAS Standards can serve many purposes. Communication allows an 

organization to share its accomplishments in integrating culturally and linguistically appropriate services 

in accordance with the National CLAS Standards. It can also help institutionalize the National CLAS 

Standards by prompting the organization to regularly focus on the extent to which it has implemented 

each Standard, thereby helping to keep the organization accountable. Communicating the organization’s 
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Standard 15 134

progress also serves as a mechanism for organizations to learn from each other concerning new ideas 

and promising practices for implementing CLAS.

Organizations may exercise latitude in the information they make available and the means by which they 

report it to their stakeholders, constituents, and the general public. Examples of possible strategies are 

described in the following section. An organization that wishes to provide information can report one or 

more of the following: the results of organizational assessments (Standard 10), data collected and 

communities served (Standard 11), results of the assessments of the community health assets and needs 

(Standard 12), or the various partnerships that have been formed with other organizations from the 

community (Standard 13).

Being accountable to the public supports the continuous quality improvement process by documenting 

publicly the organization’s ability to provide quality care and services in a culturally and linguistically 

appropriate manner. It also informs the organization and community of areas needing improvement. 

Communication about CLAS may serve to actively engage the community in assessing an organization’s 

service, noting need for improvements, identifying programs that would match its needs, and charting 

related progress. Accountability is also important in situations in which an organization is using public 

funds to serve the community. Information provided to the public should be relevant, useful, and 

understandable to the community. An organization may also communicate CLAS implementation progress 

as part of its community benefits and other reporting or accountability requirements.

Strategies for Implementation 

The following are implementation strategies for being accountable to the community by presenting to the 

public progress in implementing culturally and linguistically appropriate services.

Items on which to report may include (HHS OMH, 2001):

o Demographic data about the populations

o Utilization and availability statistics related to interpreters and translated materials

o Level of staff training in cultural and linguistic competency

o CLAS-related expenditures and cost-benefit data

o Assessment results based on activities suggested from Standard 10, community data collected in 

accordance with Standard 12, and the number of complaints and their resolution as collected 

pursuant to Standard 14
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o Results from performance measures, satisfaction ratings, quality improvement and clinical 

outcome data analyses, and cost-effectiveness analyses

Strategies for presenting CLAS-related progress include:

o Draft and distribute materials that demonstrate efforts to be culturally and linguistically 

responsive (QSource, 2005). The materials should be easy to understand and in accordance with 

Standard 8.

o Partner with community organizations to lead discussions about the services provided and 

progress made (QSource, 2005); see also Standard 13.

o Create advisory boards to consult with community partners on issues affecting diverse 

populations and how best to serve and reach them (National Consensus Panel on Emergency 

Preparedness and Cultural Diversity, 2011).

o Engage community-based workers to help craft and deliver messages and implications of data. 

Community outreach that is culturally and linguistically tailored and provided by trusted 

messengers is central to ensuring messages are received, understood, and adhered to by local 

members of the community. Community-based workers are seen as trusted sources of health 

information and can help with reaching and educating communities (National Consensus Panel on 

Emergency Preparedness and Cultural Diversity, 2011).

o Convene educational forums. Agencies may consider partnering with well-respected and trusted 

community-based organizations to host regional educational forums, inviting local community 

representatives to participate. Educational forums are intended to provide education, materials, 

and information on topics of most concern to communities — whether regarding public health, 

public safety, or primary care. At the same time, they include feedback sessions, where 

community partners and representatives can assess and evaluate the validity and application of 

recommendations, resources, and materials to their communities’ cultural, social, and economic 

circumstances (National Consensus Panel on Emergency Preparedness and Cultural Diversity, 

2011).

Resources 

Clinical and Translational Science Awards Consortium, Community Engagement Key Function Committee 

Task Force on the Principles of Community Engagement. (2011). Principles of community 

engagement (2nd ed.) (National Institutes of Health Publication No. 11-7782). Retrieved from 

http://www.atsdr.cdc.gov/communityengagement/pdf/PCE_Report_508_FINAL.pdf
National Standards for CLAS in Health and Health Care:

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Standard 15 136

National Committee for Quality Assurance. (2011). Awards: Recognizing innovations in multicultural 

health care. Retrieved from http://www.ncqa.org/tabid/453/Default.aspx

National Consensus Panel on Emergency Preparedness and Cultural Diversity. (2011). Guidance for 

integrating culturally diverse communities into planning for and responding to emergencies: A 

toolkit. Recommendations of the National Consensus Panel on Emergency Preparedness and 

Cultural Diversity (HHS Office of Minority Health Publication No. OMH-NHMA-5-10). Retrieved 

from 

http://www.hhs.gov/ocr/civilrights/resources/specialtopics/emergencypre/omh_diversitytoolkit.pd

f

Ohmans, P., & Cushing, M. (2000). Getting the word out: Effective health outreach to cultural 

communities. Retrieved from The Medtronic Foundation website: 

http://www.medtronic.com/downloadablefiles/outreach_brochure.pdf

Sandrick, K. (2006). Defining and measuring community benefit. Trustee, 59(9), 6–10. Retrieved from 

http://www.trusteemag.com/trusteemag_app/jsp/articledisplay.jsp?dcrpath=TRUSTEEMAG/Pubs

NewsArticleGen/data/2006October/0610TRU_CoverStory&domain=TRUSTEEMAG

U.S. Department of Health and Human Services, Health Resources and Services Administration. (2001). 

Cultural competence works: Using cultural competence to improve the quality of health care for 

diverse populations and add value to managed care arrangements. Retrieved from 

ftp://ftp.hrsa.gov/financeMC/cultural-competence.pdf

Additional resources can be found in Appendix E and at www.ThinkCulturalHealth.hhs.gov.

Bibliography 

National Consensus Panel on Emergency Preparedness and Cultural Diversity. (2011). Guidance for 

integrating culturally diverse communities into planning for and responding to emergencies: A 

toolkit. Recommendations of the National Consensus Panel on Emergency Preparedness and 

Cultural Diversity (HHS Office of Minority Health Publication No. OMH-NHMA-5-10). Retrieved 

from 

http://www.hhs.gov/ocr/civilrights/resources/specialtopics/emergencypre/omh_diversitytoolkit.pd

f

QSource, Underserved Quality Improvement Organization Support Center. (2005). CLAS Standards 

implementation tips. Retrieved from 

http://www.qsource.org/uqiosc/CLAS%20Standards%20Strategies%5B7AUG-2005%5D.pdf

U.S. Department of Health and Human Services, Office of Minority Health. (2001). National standards for 

culturally and linguistically appropriate services in health care: Final report. Retrieved from 

http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf
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Appendix A: Glossary

Acculturation:1 The exchange of cultural features that results when groups of individuals having 

different cultures come into continuous firsthand contact; the original cultural patterns of either or both 

groups may be altered, but the groups remain distinct.

Augmentative and Alternative Communication (AAC) Resources:2 Systems or devices that 

attempt to temporarily or permanently compensate for and facilitate the impairment and disability of 

individuals with severe expressive or language comprehension disorders. AAC may be required for 

individuals demonstrating impairments in gestural, spoken, and/or written modalities.

Auxiliary Aids and Services:3 Devices or services that enable effective communication for people with 

disabilities. Examples include qualified interpreters, note takers, transcription services, written materials, 

assistive listening devices and systems, telephone communication devices for deaf persons, telephone 

handset amplifiers, video interpretive services, and open and closed captioning.

Bilingual:4 A term describing a person who has some degree of proficiency in two languages. A high 

level of bilingualism is the most basic of the qualifications of a competent interpreter but, by itself, does 

not ensure the ability to interpret.

Bisexual:5 One whose sexual or romantic attractions and behaviors are directed at members of both 

sexes to a significant degree.

Caregiver:6 An individual who assists another person who because of physical disability, chronic illness, 

or cognitive impairment is unable to perform certain activities on his/her own. So-called informal care can 

be offered by family members or friends, often in a home setting. Paid or volunteer professional care, or 

so-called formal care, can be obtained at home, in the community, or from institutions such as nursing 

facilities or government institutions.

Certification:7 A process by which a certifying body (usually a governmental or professional 

organization) attests to an individual’s qualifications to provide a particular service. Certification calls for 

formal assessment using an instrument that has been tested for validity and reliability so that the 

certifying body can be confident that the individuals it certifies have the qualifications needed to do the 

job.

Certified Interpreter:8 An interpreter who is certified as competent by a professional organization or 

government entity through rigorous testing based on appropriate and consistent criteria. Interpreters 

who have had limited training — or have only taken a screening test administered by an employing 

health, interpreter, or referral agency — are not considered certified.
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Communication Needs:9 Difficulty with some aspects of communicating. This difficulty may be minor 

and temporary or more complex and long term. The term “needs” refers both to the individual’s needs 

and to what society can do to support the individual by examining the individual and the environments in 

which he/she interacts.

Requirements of the Americans with Disabilities Act communication needs extend beyond spoken 

language capability to include barriers imposed by disabilities affecting hearing, speech, and vision.10

Community Health Assessment/Community Health Needs Assessment (CHNA):11 Community 

health assessment is a systematic examination of the health status indicators for a given population that 

is used to identify key problems and assets in a community. The ultimate goal of a community health 

assessment is to develop strategies to address the community’s health needs and identified issues.

Community Needs Assessment:12 A community needs assessment identifies the strengths and 

resources available in the community to meet its needs. The assessment focuses on the capabilities of 

the community, including its citizens, agencies, and organizations. It provides a framework for developing 

and identifying services and solutions and building communities that support and nurture health and 

wellness.

A community needs assessment may be limited to a compilation of demographic data from census 

records, results of surveys conducted by others, and informal feedback from community partners. 

Alternatively, assessments may be expanded to include focus group discussions, town meetings, 

interviews with stakeholders, and telephone or mailed surveys to partnership members and the 

community.

Continuous Quality Improvement:13 The complete process of identifying, describing, and analyzing 

strengths and problems and then testing, implementing, learning from, and revising solutions. It relies on 

an organizational and/or system culture that is proactive and supports continuous learning. Continuous 

quality improvement is firmly grounded in the overall mission, vision, and values of the agency/system. 

Perhaps most important, it is dependent upon the active inclusion and participation of staff at all levels of 

the agency/system — children, youth, families, and stakeholders — throughout the process.

CLAS: See “Culturally and Linguistically Appropriate Services.”

CLAS Standards: See “National CLAS Standards.”

Cultural Broker:14 Individuals from the community who serve as bridges between an organization and 

people of different cultural backgrounds.

Cultural and Linguistic Competency:15 The capacity for individuals and organizations to work and 

communicate effectively in cross-cultural situations through the adoption and implementation of 
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strategies to ensure appropriate awareness, attitudes, and actions and through the use of policies, 

structures, practices, procedures, and dedicated resources that support this capacity.

o Cultural Competency: A developmental process in which individuals or institutions achieve 

increasing levels of awareness, knowledge, and skills along a cultural competence continuum. 

Cultural competence involves valuing diversity, conducting self-assessments, avoiding 

stereotypes, managing the dynamics of difference, acquiring and institutionalizing cultural 

knowledge, and adapting to diversity and cultural contexts in communities.

o Linguistic Competency: The capacity of individuals or institutions to communicate effectively 

at every point of contact. Effective communication includes the ability to convey information —

both written and oral — in a manner that is easily understood by diverse groups, including 

persons of limited English proficiency, those who have low literacy skills or who are not literate, 

those having low health literacy, those with disabilities, and those who are deaf or hard of 

hearing.

Culturally and Linguistically Appropriate Services (CLAS):16 Services that are respectful of and 

responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, 

and communication needs and employed by all members of an organization (regardless of size) at every 

point of contact.

Culture:17,18 The integrated pattern of thoughts, communications, actions, customs, beliefs, values, and 

institutions associated, wholly or partially, with racial, ethnic, or linguistic groups as well as religious, 

spiritual, biological, geographical, or sociological characteristics. Culture is dynamic in nature, and 

individuals may identify with multiple cultures over the course of their lifetimes.

Elements of culture include, but are not limited to, the following:

o Age

o Cognitive ability or limitations

o Country of origin

o Degree of acculturation

o Educational level attained

o Environment and surroundings

o Family and household composition

o Gender identity

o Generation

o Health practices, including use of traditional healer techniques such as Reiki and acupuncture.
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o Linguistic characteristics, including language(s) spoken, written, or signed; dialects or regional 

variants; literacy levels; and other related communication needs.

o Military affiliation

o Occupational groups

o Perceptions of family and community

o Perceptions of health and well-being and related practices

o Perceptions/beliefs regarding diet and nutrition

o Physical ability or limitations

o Political beliefs

o Racial and ethnic groups include — but are not limited to — those defined by the U.S. Census 

Bureau.

o Religious and spiritual characteristics, including beliefs, practices, and support systems related to 

how an individual finds and defines meaning in his/her life.

o Residence (i.e., urban, rural, or suburban)

o Sex

o Sexual orientation

o Socioeconomic status

Determinants of Health:19 Determinants of health care factors that influence health status and 

determine health differentials or health inequalities. They are many and varied and include, for example, 

natural biological factors, such as age, gender, and ethnicity; behavior and lifestyles, such as smoking, 

alcohol consumption, diet, and physical exercise; the physical and social environment, including housing 

quality, the workplace, and the wider urban and rural environment; and access to health care.

Effective Communication:20 The successful joint establishment of meaning wherein patients and 

health care providers exchange information, enabling patients to participate actively in their care from 

admission through discharge and ensuring that the responsibilities of both patients and providers are 

understood. To be truly effective, communication requires a two-way process (expressive and receptive) 

in which messages are negotiated until the information is correctly understood by both parties. Successful 

communication takes place only when providers understand and integrate the information gleaned from 

patients and when patients comprehend accurate, timely, complete, and unambiguous messages from 

providers in a way that enables them to participate responsibly in their care.

Ethnicity:21 The Office of Management and Budget requires federal agencies to use a minimum of two 

ethnicities: Hispanic or Latino and Not Hispanic or Latino. Hispanic origin can be viewed as the heritage, 

nationality group, lineage, or country of birth of the person or the person’s parents or ancestors before 

their arrival in the United States. People who identify their origin as Hispanic, Latino, or Spanish may be 

of any race.
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Gay:22 An attraction and/or behavior focused exclusively or mainly on members of the same sex or 

gender identity; a personal or social identity based on one’s same-sex attractions and membership in a 

sexual-minority community.

Gender Expression:23 Characteristics in appearance, personality, and behavior culturally defined as 

masculine or feminine.

Gender Identity:

24 One’s basic sense of being a man, woman, or other gender.

Health:25,26,27 Health encompasses many aspects, including physical, mental, social, and spiritual wellbeing. The World Health Organization also notes that health is “not merely the absence of disease or 

infirmity.”

Health Care:28 According to the Health Insurance Portability and Accountability Act of 1996, health care 

refers to the care, services, or supplies related to the health of an individual, including but not limited to, 

the following:

o Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, 

service, assessment, or a procedure with respect to the physical or mental condition, or 

functional status, of an individual or that affects the structure or function of the body; and

o Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription.

Health Care Disparities:29 Differences in the receipt of, experiences with, and quality of health care 

that are not due to access-related factors or clinical needs, preferences, or appropriateness of 

intervention.

Health Care Organization:30 Any public or private institution involved in any aspect of delivering 

health care services.

Health Disparity:31 A particular type of health difference that is closely linked with social, economic, 

and/or environmental disadvantage. Health disparities adversely affect groups of people who have 

systematically experienced greater obstacles to health based on their racial or ethnic group; religion; 

socio-economic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual 

orientation or gender identity; geographic location; or other characteristics historically linked to 

discrimination or exclusion.

Health Equity:32,33 Attainment of the highest level of health for all people. Achieving health equity 

requires valuing everyone equally, with focused and ongoing societal efforts to address avoidable 

inequalities, historical and contemporary injustices, and the elimination of health and health care 

disparities.
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Health Inequality:34 Difference in health status or in the distribution of health determinants among 

different population groups. For example, differences in mobility between elderly people and younger 

populations or differences in mortality rates among people from different social classes. It is important to 

distinguish between a health inequality and a health inequity. Some health inequalities are attributable to 

biological variations or free choice, while others are attributable to the external environment and 

conditions mainly outside the control of the individuals concerned. In the first case, it may be impossible 

or ethically or ideologically unacceptable to change the health determinants, and so the resultant health 

inequality is unavoidable. In the second case, the uneven distribution may be unnecessary and avoidable 

as well as unjust and unfair so that the resulting health inequalities also lead to an inequity in health.

Health Inequities:35 Differences in health status or in the distribution of health determinants among 

different population groups.

Health Literacy:36 The degree to which an individual has the capacity to obtain, process, and 

understand basic health information and services needed to make appropriate health decisions.

Health Numeracy:37 The degree to which an individual has the capacity to access, process, interpret, 

communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health 

information needed to make effective health decisions.

Health Organization:38 Any public or private institution addressing individual or community health and 

well-being.

Individuals and Groups:

39 Patients, clients, or consumers, including accompanying family members, 

guardians, or companions, seeking physical, mental, or other health-related services.

Interpreter:40 An individual who renders a message spoken or signed in one language into a second 

language and who abides by a code of professional ethics.

Types of Interpreters:

o Ad Hoc Interpreter:41 An untrained individual who is called upon to interpret, such as a family 

member interpreting for his/her parents, a bilingual staff member pulled away from other duties 

to interpret, or a self-declared bilingual in a hospital waiting room who volunteers to interpret. 

Also called a chance interpreter or lay interpreter.

o Bilingual Provider:42 An individual with proficiency in more than one language, enabling the 

person to provide services directly to limited English proficient patients in their non-English 

language.
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o Bilingual Worker/Employee:43 An employee who is a proficient speaker of two languages and 

who may provide direct services in both languages but who, without additional training, is not 

qualified to serve as an interpreter.

o Dual-Role Interpreter:44 A bilingual employee in health care who has been tested for 

language skills and trained as a medical interpreter and who assumes the task of part-time 

medical interpreting willingly.

o Qualified Interpreter:45 An individual who has been assessed for professional skills, 

demonstrates a high level of proficiency in at least two languages, and has the appropriate 

training and experience to interpret with skill and accuracy while adhering to the National Code of 

Ethics and Standards of Practice published by the National Council on Interpreting in Health Care.

Interpreting:46

o (noun) The process of understanding and analyzing a spoken or signed message and 

re-expressing that message faithfully, accurately, and objectively in another language, taking the 

cultural and social context into account. The purpose of interpreting is to enable communication 

between two or more individuals who do not speak one another’s languages.

o (adjective) Concerning or involved with interpreting. Examples are interpreting services, 

interpreting issues.

Types of Interpreting:

o Community Interpreting:47 Interpreting that takes place in the course of communication in 

the local community among speakers of different languages. The community interpreter may or 

may not be a trained interpreter. Community settings include schools, social service agencies, 

clinics, legal services, and businesses that serve a diverse clientele.

o Consecutive Interpreting:48 A highly complex cognitive activity that requires the interpreter to 

listen, analyze, comprehend, convert, edit, and reproduce the original message, after the speaker 

or signer pauses, in a specific social context. Consecutive interpretation is likely to take longer 

than simultaneous, because the interpreter does not interpret while the speaker or signer is 

speaking or signing.

o Face-to-Face Interpreting:49 Interpreting in which the interpreter is present, in person, with 

both, or at least one, of the persons for whom interpreting is provided.

o First-Person Interpreting:50 The promotion by the interpreter of direct communication 

between the principal parties in the interaction through the use of direct utterances of each of 
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the speakers, as though the interpreter were the voice of the person speaking, albeit in the 

language of the listener. For example, if the patient says, “My stomach hurts,” the interpreter 

says (in the second language), “My stomach hurts,” not “She says her stomach hurts.”

o Health Care Interpreting:51 Interpreting that takes place in health care settings of any sort, 

including doctors’ offices, clinics, hospitals, home health visits, mental health clinics, and public 

health presentations. Typically, the setting is an interview between a health care provider 

(doctor, nurse, lab technician) and a patient (or the patient and one or more family members).

o Simultaneous Interpretation:52 Highly complex cognitive activity that requires the interpreter 

to listen, analyze, comprehend, convert, edit, and reproduce in real time a speaker or signer’s 

message while the speaker or signer continues to speak or sign, in a specific social context.

o Telephone or Telephonic Interpreting:53 Interpreting carried out remotely, with the 

interpreter connected by telephone to the principal parties, typically provided through a 

speakerphone or headsets. In health care settings, the principal parties, e.g., doctor and patient, 

are normally in the same room, but telephone interpreting can be used to serve individuals who 

are also connected to each other only by telephone.

o Video Remote Interpreting (VRI):54 An interpreting service that uses video conference 

technology over dedicated lines or wireless technology offering a high-speed, wide-bandwidth 

video connection that delivers high-quality video images. To ensure that VRI is effective, the 

Department of Justice has established performance standards for VRI and requires training for 

users of the technology and other individuals involved with its use so that they may quickly and 

efficiently set up and operate the VRI system.

Language:55 While the Office of Budget and Management has not established a list of language 

categories, the collection of language data has been pivotal in determining whether there has been 

discrimination by “national origin” under Title VI of the Civil Rights Act of 1964, and federal policies state 

that “reasonable steps” need to be taken so that persons of limited English proficiency can have 

“meaningful access” to programs or activities without charge for language services. Additionally, in 2000, 

the Department of Health and Human Services released its National Standards on Culturally and 

Linguistically Appropriate Services, which encourages all health care organizations and individual 

providers “to make their practices more culturally and linguistically accessible,” including the use of race, 

ethnicity, and language data in program assessments and incorporation of these data into health records 

and organizational management systems.

Language Assistance Services:56 Mechanisms used to facilitate communication with individuals who 

do not speak English, those who have limited English proficiency, and those who are deaf or hard of 
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hearing. These services can include in-person interpreters, bilingual staff, or remote interpreting systems 

such as telephone or video interpreting. Language services also refer to processes in place to provide 

translation of written materials or signage, sign language, or braille materials.

Language Concordance:57 Occurs when the individual seeking services or care and the provider of 

said services are able to speak the same primary language well.

Lesbian:58 A woman who self-identifies as having an emotional, sexual, and/or relational attraction to 

other women.

Limited English Proficiency:59,60 A concept referring to a level of English proficiency that is insufficient 

to ensure equal access to public services without language assistance with respect to a particular type of 

service, benefit, or encounter.

Meaningful Access:61 Recipients of federal financial assistance are required to take reasonable steps to 

ensure meaningful access to their programs and activities by limited English proficient (LEP) persons.

The HHS Office of Civil Rights Guidance explains that the obligation to provide meaningful access is fact 

dependent and starts with an individualized assessment that balances four factors: (1) the number or 

proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee; (2) 

the frequency with which LEP individuals come into contact with the program; (3) the nature and 

importance of the program, activity, or service provided by the recipient to its beneficiaries; and (4) the 

resources available to the grantee/recipient and the costs of interpretation/translation services. There is 

no one-size-fits-all solution for Title VI compliance with respect to LEP persons, and what constitutes 

"reasonable steps" for large providers may not be reasonable where small providers are concerned.

National CLAS Standards:62 The framework for culturally and linguistically appropriate services issued 

by the U.S. Department of Health and Human Services, Office of Minority Health. The National CLAS 

Standards are intended to inform, guide, and facilitate practices related to culturally and linguistically 

appropriate health service delivery.

Numeracy:63 A part of literacy that implies a facility with basic probability and numerical concepts.

Plain Language:64 A strategy for making written and oral information easier to understand; 

communication that users can understand the first time they read or hear it. A plain language document 

is one in which people can find what they need, understand what they find, and act appropriately on that 

understanding.

Primary Language:65 The language that a limited English proficient individual identifies as the one that 

he/she uses to communicate effectively and would prefer to use to communicate with service providers.
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Race:66 The Department of Health and Human Services and its agencies follow the racial categories 

developed by the Office of Management and Budget and used by the U.S. census. These categories 

generally reflect a social definition of race recognized in this country and are not an attempt to define 

race biologically, anthropologically, or genetically. People may choose to report more than one race to 

indicate their racial mixture, such as “American Indian and White.”

People who identify their origin as Hispanic, Latino, or Spanish may be of any race. Racial categories can 

include national origin or sociocultural groups.

Information on race is required for many federal programs and is important for making policy decisions, 

particularly for civil rights. States use these data to meet legislative redistricting principles. Race data also 

are used to promote equal employment opportunities and to assess environmental risks and racial 

disparities in health.

Reasonable Steps: For guidance on how to determine whether the steps taken to provide language 

access are “reasonable,” providers or organizations should refer to the Department of Health and Human 

Services’ Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against 

National Origin Discrimination Affecting Limited English Proficient Persons.

Sex:67 The Department of Health and Human Services and its agencies follow the sex categories 

developed by the Office of Management and Budget and used by the U.S. census. The census 

operationalizes sex as “male” or “female.” The census question regarding sex remains unchanged from 

the previous census. Information on the sex of individuals is one of the few items obtained in the original 

1790 census and in every census since.

It is important to note that sex differs from the concepts of gender, gender identity, and gender 

expression.

Sexual Identity:

68 Encompasses attraction, behavior, and identity. Most researchers studying sexual 

orientation have defined it operationally in terms of one or more of the following components. Defined in 

terms of behavior, sexual orientation refers to an enduring pattern of sexual or romantic activity with 

men, women, or both sexes. Defined in terms of attraction (or desire), it denotes an enduring pattern of 

experiencing sexual or romantic feelings for men, women, or both sexes. Identity encompasses both 

personal identity and social identity. Defined in terms of personal identity, sexual orientation refers to a 

conception of the self-based on one’s enduring pattern of sexual and romantic attractions and behaviors 

toward men, women, or both sexes. Defined in terms of social (or collective) identity, it refers to a sense 

of membership in a social group based on a shared sexual orientation and a linkage of one’s self-esteem 

to that group.
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Social Determinants of Health:69 The conditions in which people are born, grow, live, work, and age, 

including the health system.

Staff:70 The group of individuals formally affiliated with an institution, including paid employees, 

contractors, and unpaid volunteers.

Threshold Population:71 A threshold population is a linguistic group that makes up 15% or more of a 

program’s clients and who share a common language other than English as a primary language. For 

example, if program XYZ serves 200 clients, and at least 30 of them speak Haitian-Creole as a primary 

language, that group would be considered a threshold population for that program, and Haitian-Creole 

would be considered a threshold language. Some programs may target multiple groups and, therefore, 

may have multiple threshold populations and threshold languages; some programs may have no 

threshold populations.

Traditional Healer Services:

72 The application of knowledge, skills, and practices based on the 

experiences indigenous to different cultures. These services are directed towards the maintenance of 

health, as well as the prevention, diagnosis, and improvement of physical and mental illness. Examples of 

traditional healers include herbalists, faith healers, and practitioners of Chinese or Ayurvedic medicine. In 

contrast, allopathic service providers are those trained in western medicine.

Transgender:

73 A person whose gender identity and/or expression is different from that typically 

associated with their assigned sex at birth.

Translation:74 The conversion of a written text into a corresponding written text in a different language.

Translator:75 A person who translates written texts.

TTY:76 TTY stands for text telephone. It is also sometimes called a TDD, or telecommunication device for 

the deaf. TTY is the more widely accepted term, however, as TTYs are used by many people, not just 

people who are deaf.

Vital Documents:77 For the purposes of ensuring language access, vital documents are written 

documents that are “vital” to programs or limited English proficient populations. Examples include signs, 

directions, and notices about the availability of interpreter services, client intake forms, and legal 

documents (e.g., consent forms, notices of client rights and responsibilities, privacy notices, complaint 

forms, grievance policies).
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Bibliography

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42 National Council on Interpreting in Health Care. (2008). The terminology of health care interpreting: A 

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http://data.memberclicks.com/site/ncihc/NCIHC%20Terms%20Final080408.pdf

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National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

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50 National Council on Interpreting in Health Care. (2008). The terminology of health care interpreting: A 

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51 National Council on Interpreting in Health Care. (2008). The terminology of health care interpreting: A 

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52 ASTM, International. (2007). Standard guide for language interpretation services. doi:10.1520/F2089-

01R07

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74 National Council on Interpreting in Health Care. (2008). The terminology of health care interpreting: A 

glossary of terms. Retrieved from 

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National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

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75 National Council on Interpreting in Health Care. (2008). The terminology of health care interpreting: A 

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76 AboutTTY.com: The power of connecting. (n.d.). What is a TTY? Retrieved from 

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National Standards for CLAS in Health and Health Care:

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Appendix B: National CLAS Standards Enhancement Initiative 155

Appendix B: National CLAS Standards Enhancement Initiative

Background 

In 2000, the Office of Minority Health at the U.S. Department of Health and Human Services published 

the National Standards for Culturally and Linguistically Appropriate Services in Health Care, known as the 

National CLAS Standards. The development process began in 1999, when the Office of Minority Health 

convened key stakeholders to begin crafting a set of national standards that would guide the care 

provided to the nation’s culturally and linguistically diverse populations. Published in 2000, the National 

Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report resulted from 

extensive research, discussions, and input from thousands of citizens. The original National CLAS 

Standards provided a common understanding and guidance regarding cultural and linguistic competency, 

with the ultimate goal of reducing racial and ethnic health disparities.

The original National CLAS Standards, the first of their kind, have served as catalyst and conduit for 

efforts to improve quality of care and achieve health equity over the past 10 years. In recognition of 

those vast changes, the Office of Minority Health undertook the National CLAS Standards Enhancement 

Initiative from 2010 to 2012. Although much progress has been made toward universal implementation of 

culturally and linguistically appropriate services, there is still much work to be done. The enhanced 

National CLAS Standards seek to set a new bar for culturally and linguistically appropriate services to 

improve the health of our ever-diversifying communities.

Goals 

o To examine the National CLAS Standards, originally promulgated in 2000, for their relevance and 

applicability to the 21st century

o To have the enhanced National CLAS Standards serve as the cornerstone for culturally and 

linguistically appropriate services in the United States

o To launch new and innovative promotion and marketing initiatives for the National CLAS 

Standards

o To coordinate the National CLAS Standards Enhancement Initiative with the Affordable Care Act 

and other cultural and linguistic competency standards (e.g., The Joint Commission, National 

Committee for Quality Assurance)

o To address the following areas throughout the enhancement initiative process:
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix B: National CLAS Standards Enhancement Initiative 156

• Increase awareness regarding the importance and influence of cultural and linguistic 

competency

• Increase impact of National CLAS Standards by expanding scope, audience, and 

inclusivity

• Ensure the National CLAS Standards converge with the organization’s quality 

improvement efforts

• Assist in the implementation of the Standards through additional resources

• Incorporate health literacy

• Promote the importance of research regarding the efficacy of the Standards

• Address advancements and developments in the field, including health care reform

o To promulgate an enhanced version of the National CLAS Standards

Development Process 

Discussions began in 2009 at the HHS Office of Minority Health regarding a plan to enhance the National 

CLAS Standards. The National CLAS Standards Enhancement Initiative formally began in 2010 following 

the same development process as the original National CLAS Standards project in 1999–2001. The 

development process had three major components: public comment, the Advisory Committee, and a 

systematic literature review. 

Figure 4: Phases of the National CLAS Standards Enhancement Initiative

o Public Comment: Three regional public meetings were held in fall 2010 in the same locations 

as in the 2001 National CLAS Standards’ development: Baltimore, MD; Chicago, IL; and San 

Francisco, CA. Public comment was also collected via written and online submissions during the 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix B: National CLAS Standards Enhancement Initiative 157

same time period. A public comment meeting report and a public comment online and written 

submissions report are available online at www.ThinkCulturalHealth.hhs.gov.

o National Project Advisory Committee: A National Project Advisory Committee was convened 

in 2010 and provided input and review throughout the development process, including several inperson and virtual meetings. Members of the Advisory Committee represent the public, private, 

and government sectors. It includes stakeholders representing a variety of health settings, such 

as managed care, community health centers, insurance providers, local and state health 

departments, community- and faith-based organizations, and federal government officials.

o Systematic Literature Review : A systematic literature review was developed in 2010 to use 

as foundational knowledge for the Enhancement Initiative. This report provided a synthesis of 

accomplishments, advances, and promising practices in the field since the publication of the 

National CLAS Standards in 2000.

Public Comment 

Public comment was collected in fall 2010 through meetings across the country, an online submission 

portal, and written submissions. The announcement of the public comment opportunities appeared in the 

Federal Register published on Sept. 23, 2010.

Public Comment Meetings

Three public comment meetings were held:

o Baltimore, MD; Oct. 22, 2010

o San Francisco, CA; Nov. 4, 2010

o Chicago, IL; Nov. 15, 2010

Each public comment meeting gathered detailed input from individuals and organizations. It included 

open-microphone public comment and small group discussions with guided questions and group 

feedback. The following themes arose from the comments heard across the three meetings.
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A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix B: National CLAS Standards Enhancement Initiative 158

The enhanced National CLAS Standards should:

o Encompass a broad definition of culture to include religion and spirituality; the lesbian, gay, 

bisexual, and transgender community; deaf and hard of hearing individuals; and individuals with 

limited vision

o Incorporate the areas of patient satisfaction and safety

o Address issues of health literacy

o Establish congruency with other standards in the field

o Be action oriented

o Reflect advancements in terminology, technology, and more, including medical homes, electronic 

health records, and language access

Written and Online Public Comment

Written and online public comment was collected from Sept. 20, 2010, to Dec. 31, 2010. The following 

overarching themes emerged:

The National CLAS Standards should:

o Expand the target audience beyond health care organizations

o Encompass a broad definition of culture to include religion and spirituality; the lesbian, gay, 

bisexual, and transgender community; hard of hearing and deaf individuals; and individuals with 

limited vision

o Offer more guidance within the Standards pertaining to language assistance services

o Establish congruency with other Standards in the field

National Project Advisory Committee 

The National CLAS Standards Enhancement Initiative’s National Project Advisory Committee comprises 36 

experts in the fields of cultural and linguistic competency representing HHS agencies, academic 

institutions, health associations, and other not-for-profit organizations. The Advisory Committee provided 

insight, recommendations, and review throughout the development of the enhanced Standards and the 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix B: National CLAS Standards Enhancement Initiative 159

Blueprint. The Enhancement Initiative Project Team2 convened several meetings with the Advisory 

Committee throughout the Enhancement Initiative, either in person or virtually (see Figure 5).

Figure 5: Advisory Committee Meetings

The Project Team conducted informal interviews in fall 2010 with the members of the Advisory 

Committee in order to gather input on the National CLAS Standards from subject matter experts 

representing a myriad of roles in the field of cultural and linguistic competency. These conversations, 

along with the public comment and the systematic literature review, served to begin the laying of the 

foundation for the enhanced National CLAS Standards in fall 2010. The topics of discussion included the 

purpose and scope of the future National CLAS Standards, the target audience, and issues surrounding 

implementation and promotion.

At the January 2011 meeting, the Advisory Committee discussed the following topics in depth:

 

2 The Enhancement Initiative Project Team was managed by an outside contractor. Team members are identified in Appendix C.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix B: National CLAS Standards Enhancement Initiative 160

o Purpose

o Definitions

o Inclusivity

o Audience

o Health Literacy

o Language Access Services

o Measurements

o Implementation

o Promotion

o End Product

The January 2011 meeting built the framework for the project team to begin drafting the enhanced 

National CLAS Standards. During spring 2011, the Advisory Committee reviewed and provided feedback 

on a document of terminology and definitions that would serve as the conceptual underpinning of the 

enhanced National CLAS Standards. The Advisory Committee met virtually for a series of webinars in 

summer 2011 to define the direction of the enhanced National CLAS Standards and discuss draft 

Standards. In addition, the committee members began compiling information and materials for the 

guidance document to accompany the enhanced National CLAS Standards. 

The Advisory Committee provided in-depth reviews of the enhanced Standards’ drafts in late summer and 

fall 2011. It also reviewed a draft of this guidance document to be published with the National CLAS 

Standards. The Advisory Committee met in December 2011 to finalize the National CLAS Standards and 

its report and make plans for the next steps.

Systematic Literature Review

The systematic literature review, developed in 2010, discusses the evolution of the efforts to improve 

cultural and linguistic appropriateness since the release of the National CLAS Standards in 2000. 
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix B: Glossary 161

It addresses the broad dissemination, promotion, and implementation nationwide of the National CLAS 

Standards and the concepts of CLAS. In addition, the report covers cultural competency education 

initiatives; adoption of CLAS at the federal, state, and organizational levels; changes in accreditation 

standards to explicitly include CLAS; the proliferation of technical assistance regarding CLAS; and 

research and evaluation of the National CLAS Standards’ impact. The report concludes with areas for 

consideration that emerged from the literature and research of the last 10 years, which provided insight 

into the issues the enhanced National CLAS Standards should address.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix C: National Project Advisory Committee 162

Appendix C: National Project Advisory Committee

Affiliations listed for identification purposes only; no endorsement of this report by Advisory Committee 

members or their employers should be inferred.

Wilma Alvarado-Little, M.A., M.S.W.

Albany, New York

Chair of the Policy and Research Committee, 

National Council on Interpreting in Health Care

Director of the Community Engagement/ 

Outreach Core, Center for the Elimination of 

Minority Health Disparities at the University of 

Albany, 

State University of New York

Dennis Andrulis, Ph.D., M.P.H.

Austin, Texas

Associate Professor, University of Texas School 

of Public Health

Senior Research Scientist, Texas Health Institute

Frances E. Ashe-Goins, R.N., M.P.H.

Washington, District of Columbia

Deputy Director

Office on Women’s Health

U.S. Department of Health and Human Services

George Askew, M.D.

Washington, District of Columbia

Chief Medical Officer

Administration for Children and Families

U.S. Department of Health and Human Services

Arlene Austin

Baltimore, Maryland

Director

Office of Equal Opportunity and Civil Rights

Centers for Medicare and Medicaid Services

U.S. Department of Health and Human Services

Charlene Avery, M.D.

Rockville, Maryland

Director

Office of Clinical and Preventive Services

Indian Health Service

U.S. Department of Health and Human Services

Lynne Bergero, M.H.S.A.

Oakbrook Terrace, Illinois

Project Director in the Division of Healthcare 

Quality Evaluation, The Joint Commission

Cindy Brach, M.P.P.

Rockville, Maryland

Senior Health Policy Researcher 

Agency for Healthcare Research and Quality

U.S. Department of Health and Human Services

Jessica Briefer French, M.H.S.A.

Washington, District of Columbia

Senior Consultant for Research, National 

Committee for Quality Assurance

Jeffrey Caballero, M.P.H.

Oakland, California

Executive Director, Association of Asian Pacific 

Community Health Organizations

Carol Crecy

Washington, District of Columbia

Aging Program Specialist

Administration for Community Living

U.S. Department of Health and Human Services

Linda Cummings, Ph.D.

Washington, District of Columbia

Vice President, National Association of Public 

Hospitals and Health Systems

Director, The National Public Health and Hospital 

Institute

Irene Dankwa-Mullan, M.D., M.P.H.

Bethesda, Maryland

Medical Officer

Division of Scientific Programs

National Institutes of Health

U.S. Department of Health and Human Services
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix C: National Project Advisory Committee 163

Kim Drumgo

Durham, North Carolina

Chief Diversity Official, Blue Cross Blue Shield of 

North Carolina

Willarda V. Edwards, M.D., M.B.A.

Baltimore, Maryland

Past President, National Medical Association

Leonard Epstein, MSW

Rockville, Maryland

Senior Advisor 

Clinical Quality and Culture

Health Resources and Services Administration

U.S. Department of Health and Human Services

Ron Finch, Ed.D.

Washington, District of Columbia

Vice President, National Business Group on 

Health

Iris Garcia-Caban, Ph.D.

Quincy, Massachusetts

Performance Improvement Policy Analyst, 

Massachusetts Executive Office of Health and 

Human Services Medicaid Program

Rose Gonzalez, Ph.D., M.P.S., R.N.

Silver Spring, Maryland

Director of Government Affairs, American Nurses 

Association

Tawara Goode, M.A.

Washington, District of Columbia

Assistant Professor & Director, National Center 

for Cultural Competence, Georgetown University 

Fred Hobby, M.A., CDM

Chicago, Illinois

President and CEO, Institute For Diversity in 

Health Management of the American Hospital 

Association

Roslyn Holliday Moore

Rockville, Maryland

Senior Advisor

Office of Behavioral Health Equity

Substance Abuse and Mental Health Services 

Administration

U.S. Department of Health and Human Services

Sonja Hutchins, M.D., M.P.H., Dr. P.H.

Atlanta, Georgia

Senior Medical Epidemiologist

Office of Minority Health and Health Equity

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Thomas LaVeist, Ph.D.

Baltimore, Maryland

Director, Center for Health Disparities Solutions, 

Johns Hopkins University

Heather R. Lawson, J.D., M.P.H.

Washington, District of Columbia

Civil Rights Analyst

Office for Civil Rights

U.S. Department of Health and Human Services

Robert C. Like, M.D., M.S.

New Brunswick, New Jersey

Professor and Director, Center for Healthy 

Families and Cultural Diversity, Department of 

Family Medicine and Community Health, 

University of Medicine and Dentistry of New 

Jersey – Robert Wood Johnson Medical School

Francis G. Lu, M.D.

Sacramento, California

Luke & Grace Kim Professor in Cultural 

Psychiatry and Director of Cultural Psychiatry, 

Department of Psychiatry & Behavioral Sciences, 

University of California, Davis

Luben Montoya, J.D., M.P.A.

Washington, D.C.

Supervisory Civil Rights Analyst

Office for Civil Rights

U.S. Department of Health and Human Services

Carmen Nevarez, M.D., M.P.H.

Oakland, California

Vice President of External Relations and 

Preventive Medicine Advisor, Public Health 

Institute
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix C: National Project Advisory Committee 164

Guadalupe Pacheco, M.S.W.

Rockville, Maryland

Senior Health Advisor to the Director

Office of Minority Health

U.S. Department of Health and Human Services

Elena Rios, M.D., M.S.P.H.

Washington, District of Columbia

President & CEO, National Hispanic Medical 

Association

Susan Matsuko Shinagawa

Spring Valley, California

Co-Founder & Past Chair, Asian and Pacific 

Islander National Cancer Survivors Network,

Asian & Pacific Islander American Health Forum 

Past Chair, Intercultural Cancer Council

Lisa Strumwasser

Washington, District of Columbia

Special Assistant

Office of the Assistant Secretary for Legislation

U.S. Department of Health and Human Services

Ileen Sylvester, M.B.A.

Anchorage, Alaska

Vice President of Executive and Tribal Services, 

Southcentral Foundation

Gayle Tang, M.S.N., R.N.

Oakland, California

Senior Director, National Linguistic and Diversity 

Infrastructure Management

Kaiser Permanente, National Diversity

Ho Tran, M.D., M.P.H.

San Francisco, California

President and CEO, National Council of Asian 

and Pacific Islander Physicians

Matthew K. Wynia, M.D., M.P.H., FACP

Chicago, Illinois

Director of The Institute for Ethics and The 

Center for Patient Safety, American Medical 

Association

Mara Youdelman, J.D., LLM

Washington, District of Columbia

Chair, Certificate Commission for Healthcare 

Interpreters

Senior Attorney, National Health Law Program

Enhancement Initiative Project Team

C. Godfrey Jacobs

Project Manager

SRA International, Inc.

Darci L. Graves, M.P.P., M.A., M.A.

Senior Health Education & Policy Specialist

SRA International, Inc.

Jennifer Kenyon

Senior Research Associate

SRA International, Inc.

Crystal L. Barksdale, Ph.D.

Senior Research Analyst

SRA International, Inc.
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix D: Crosswalk – National CLAS Standards 2000 and 2012 165

Appendix D: Crosswalk – National CLAS Standards 2000 and 2012

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health 

and Health Care
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix D: Crosswalk – National CLAS Standards 2000 and 2012 166
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix D: Crosswalk – National CLAS Standards 2000 and 2012 167
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix D: Crosswalk – National CLAS Standards 2000 and 2012 168
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix E: Resources 169

Appendix E: Resources

Appendix E provides an expanded list of resources, organized by the National CLAS Standards’ themes, 

that pertain to advancing and sustaining CLAS policy and practice. The table below provides an overview 

of the Standards and the themes in which they are found.

Theme Standards

Principal Standard

o Provide effective, equitable, understandable, respectful, and quality 

care and services that are responsive to diverse cultural health beliefs 

and practices, preferred languages, health literacy, and other 

communication needs.

Theme 1:

Governance, Leadership, 

and Workforce

o Advance and sustain governance and leadership that promotes CLAS 

and health equity

o Recruit, promote, and support a diverse governance, leadership, and 

workforce

o Educate and train governance, leadership, and workforce in CLAS

Theme 2:

Communication and 

Language Assistance

o Offer communication and language assistance

o Inform individuals of the availability of language assistance

o Ensure the competence of individuals providing language assistance

o Provide easy-to-understand materials and signage

Theme 3:

Engagement, 

Continuous 

Improvement, and 

Accountability

o Infuse CLAS throughout the organization’s planning and operations

o Conduct organizational assessments

o Collect and maintain demographic data

o Conduct assessments of community health assets and needs

o Partner with the community

o Create conflict and grievance resolution processes

o Communicate the organization’s progress regarding CLAS
National Standards for CLAS in Health and Health Care:

A Blueprint for Advancing and Sustaining CLAS Policy and Practice

Appendix E: Resources 170

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n%20Health%20Care%20Quality/Beach_rolerelationshipcultcomppatient%20cent_960%20pdf.pdf

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The George Washington Institute for Spirituality and Health. (n.d.). Retrieved from 

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Goldney, R. D., Fisher, L. I., & Wilson, D. H. (2001). Mental health literacy: An impediment to the 

optimum treatment of major depression in the community. Journal of Affective Disorders, 64(2–3), 277–

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Harmer, L. (1999). Health care delivery and deaf people: Practice, problems, and recommendations for 

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