Photo of female patient with medical student UC Davis clinicians work hard to provide a respectful and culturally sensitive health-care environment.

The patient is a four-year old girl. She has alpha thalassemia, an inherited disorder that affects her red blood cells and is associated with different forms of anemia. She needs bone marrow transplantation, but also suffers from a heart defect that precludes a transplant until the defect is repaired.

The case is challenging, but not entirely uncommon. Complex patient issues frequently confront physicians and other health-care professionals in large, urban hospitals like UC Davis Medical Center. What makes this particular case more challenging is that this little girl is the daughter of a Khmu couple — members of an indigenous group from Laos that fled Southeast Asia after the end of the Vietnam War. Historically, the Khmu were an agricultural society, living in isolated villages and known to practice magic and believe in spirits.

While an interpreter can be found to translate the medical advice and explanations, consider the cultural and linguistic gaps that exist between the family and their daughter's medical team. How does a care team explain an unseen malady to a family that has limited English proficiency, little experience with Western health-care practices and, in the case of the Khmu, typically involves many other family members in decision-making?

Overcoming racial and ethnic disparities

Such cases and questions might be at one end of the range of issues health-care providers deal with every day. As the Institute of Medicine's landmark, 2002 report, "Unequal Treatment," revealed, racial and ethnic disparities appear across a wide range of diseases and in a variety of clinical services and settings. Moreover, a 2007 Joint Commission report found that patients with limited English proficiency were indeed at higher risk of being mistakenly harmed in a health-care setting because of communication problems.

Photo of Sergio Aguilar-Gaxiola "UC Davis was selected to pilot this program because both our health system, and Sacramento itself, reflect highly diverse communities. It's the perfect place to test the implementation  of standards within a large health organization,  and it could become a national model for others to follow."
— Sergio Aguilar-Gaxiola, director of the UC Davis Center for Reducing Health Disparities

"With California leading the nation in diversity," says the director of the UC Davis Center for Reducing Health DisparitiesSergio Aguilar-Gaxiola, "health-care systems and their employees must be able to respond to each patient's perspective, values and behaviors regarding medicine and well-being. Failing to recognize and manage social, cultural and linguistic differences clearly can have serious health consequences."

Aguilar-Gaxiola, a professor of internal medicine and specialist in mental health care, has focused much of his career on improving cultural and linguistic competence as a way for health systems and clinicians to effectively communicate and improve care for patients from diverse backgrounds. It's one of the reasons he is leading a new training effort at UC Davis' Sacramento campus that will incorporate what are known as the Culturally and Linguistically Appropriate Services (CLAS) standards, a set of guidelines developed in 2001 by the U.S. Department of Health and Human Services' Office of Minority Health.

The CLAS standards

"The CLAS standards represent 14 key directives that we are training organizational leaders and program managers to know about and understand," says Aguilar-Gaxiola. "UC Davis was selected to pilot this program because both our health system, and Sacramento itself, reflect highly diverse communities. It's the perfect place to test the implementation of standards within a large health organization, and it could become a national model for others to follow."

Using an innovative curriculum developed by UC Davis psychiatrist Hendry Ton, more than a dozen UC Davis Health System clinical, administrative and leadership staff recently completed 16 hours of CLAS training and are now meeting on a monthly basis to refine the strategies they developed during the initial sessions for incorporating cultural and linguistic competency in their service areas.

"One of the things about learning or disseminating cultural competency," says Ton, who is an assistant clinical professor of psychiatry and behavioral sciences and director of education for the Center for Reducing Health Disparities, "is that we can't take a 'cookbook' approach to training people any more than we can take a cookbook approach to working with people from different cultures. While there are overarching themes and standards within CLAS — including culturally competent care and access to services such as available and well-trained medical interpreters — the most effective way to build new standards of care into an organization is to allow people to customize it as they see fit."

Piloting cultural competency training

UC Davis' effort to recognize and incorporate linguistic and cultural competency involves several key departments — including human resources, patient care services, patient relations and interpretive services — that are test-driving Ton's innovative CLAS training through some individual projects as a way to improve quality of care for diverse patients.

Cheryl Clyburn, manager of the Patient Relations department, says the CLAS sessions have fostered awareness and some unique collaboration that benefits both health system staff and patients.

"It was a very enlightening experience that has already had a positive impact," says Clyburn, whose department typically handles patient concerns and questions. "For example, during our discussion sessions, I began to realize that simply having a formal grievance policy wasn't enough. We needed to explore alternatives for patients whose primary language isn't English, and who might have discomfort with a formal grievance process or even a cultural stigma about 'complaining.'"

Clyburn adds that it became clear about the need to integrate the CLAS standards into the health system's formal and informal grievance processes in order to better serve an increasingly diverse patient population. The project, as she notes, is not just a sensitivity training. "It is about creating a culturally competent health system that is better able to respond to the needs of our patients and create systemic, lasting improvements."

To enhance the cultural and linguistic capabilities within her department, Clyburn began working with the university's interpreting services and its equal opportunity staff to develop new ways to ensure quality service for all patients.

"My staff needed to dig a little deeper and become more attuned to what patients were saying and how they were saying it," adds Clyburn. "I realized by developing more awareness and working collaboratively with our colleagues in the health system, we could actually implement CLAS-based improvements. In fact, we've already addressed several patient concerns that probably would not have recognized before our training."

Building awareness, establishing empathy

That type of response illustrates exactly what Hendry Ton sees as good way to enhance the core values of a health system and enhance its cultural competence.

"In a sense, this is about being in someone else's shoes," says Ton. "What we try to emphasize in our training is that by expanding your empathy toward others, you are taking a key step forward in being able to offer the best and most complete care possible to all people. And what's true for an individual employee can, over time, be true of an entire department or institution."

For the health-care team of that young Khmu girl, working to truly understand her family's concerns and put them at ease was the key to finally being able to deliver the medical care she needed. Her grandmother, still moved by age-old customs and beliefs, feared a scar from open-heart surgery would affect the youngster for eternity, including her afterlife. Respecting the grandmother's deeply held beliefs, surgeons finally overcame her apprehension by performing the procedure in a way that avoided a disfiguring scar.

The CLAS Standards represent 14 important steps that help address cases like the one involving the young patient and her family from Laos. Taking steps and being in 'someone else's shoes' can go a long way toward addressing health disparities. While CLAS is one of several concurrent efforts within the UC Davis Health System to bridge critical gaps in culture and language, the approach offers other institutions a great model for achievement and success.

UC Davis' CLAS project originated with a partnership grant to the university's Center for Reducing Health Disparities and the California Department of Health Services' Office of Multicultural Health from the U.S. Department of Human Health Services' Office of Minority Health. It is part of a national strategy to facilitate the improvement of minority health and eliminate health disparities.