NCCC Conference Call: Cultural Competence Organizational ...



NCCC Topical Conference Call # 2:

Cultural Competence Organizational Self-Assessment:

Implications for State MCH/CSHCN Programs

This call was conducted on January 31, 2002, from 3:00 – 4:30 p.m. EST

The featured speakers included:

▪ James Mason, Ph.D., Faculty, Portland State University, NCCC Senior Consultant and author of the Cultural Competence Self-Assessment Questionnaire,

▪ Trish Thomas, Outreach Project Director, Family Voices, and

▪ Richard Aronson, MD, Chief Medical Officer, Maternal and Child Health, Wisconsin Division of Public Health

Moderator: I’m here with the National Center for Cultural Competence, my name is Tawara Goode, and we welcome you to the second in a series of topical conference calls that we’re conducting in the area of cultural and linguistic competence.

For those of you who may not have had an opportunity to join us before, I’ll share with you very quickly our mission statement and a little bit as to why we are using this approach to technical assistance.

The mission of the National Center for Cultural Competence is to increase the capacity of health care and mental health programs to design, implement, and evaluate culturally and linguistically competent service delivery systems. One of our major objectives is to provide concentrated technical assistance related to cultural competence in policies, procedures, and practices. And in particular, assisting with the Maternal and Child Health Bureau’s, strategic plan. It is intended to support, through the incorporation of cultural and linguistic competence, into all aspects of Title V Children with Special Health Care Needs program, and with that said, I’d like to indicate who else is here from the National Center, and very quickly they can introduce themselves.

Clare Dunne: Hi, I’m Clare Dunne, I’m a research associate here at the NCCC.

Rosalind German: Rosalind German, a family supports coordinator.

Marisa Brown: Marisa Brown, director of the Bureau of Primary Health Care Project of the NCCC.

Suzanne Bronheim: Suzanne Bronheim, project director of the SIDS and Other Infant Death Component.

Moderator: Wendy Jones, director of the MCH project for the NCCC.

Kimberly Gordon: And Kimberly Gordon, project assistant for MCH and SIDS.

Moderator: On your agenda, it includes a welcome and purpose, and it does not include Diana Denboba, who is indeed our federal project officer, and will share perspective now.

Diana: Thank you, Tawara, I’d also like to welcome everyone, we have a wide range of people on the call, from our state Title V and MCH programs, to HRSA funded grantees in genetics, integrated services, newborn screenings, LEND programs, DMS, it’s just a wonderful diversity. We would also like to welcome our federal partners in the field offices of the Bureau of Primary Health Care Programs.

Just a little introduction to why cultural competence is important to children with special health care needs programs, above and beyond that it’s something that should be done. As Tawara had mentioned, we do have in our current MCHB strategic plan, a goal related to 100 percent of our state programs showing that they have cultural competence integrated into policies, procedures, and practices.

In addition to that, our program, along with over 170 partners, has our 2010 Express, it’s a ten-year action plan to achieve community based service systems for children and youth with special health care needs. And throughout that plan, we’ve tried to integrate cultural competence, but in particular, with goal one that relates to family serving as partners in their care and being satisfied with the services they receive.

So our programs are all trying to integrate cultural competence for a variety of reasons, and with that I’ll turn it over to our facilitator.

Moderator: This is Wendy Jones. At this time we would like to introduce our first speaker, James Mason. He is senior consultant for the NCCC and the author of Cultural Competence Self-Assessment Questionnaire that we’ve used in many of our demonstration site activities over the past five years of our work. Dr. Mason is on faculty at Portland State University, and James, would you give us a little bit of your background as it relates to cultural competence organizational self-assessments?

Dr. James Mason: Good morning Wendy, thank you. About maybe ten, fifteen years ago, I was doing research in the area of mental health, and particularly looking at services to diverse populations, and started working with Terry Cross and some other folks on developing a model called cultural competence, building on the work of people like James Lee out of the University of Washington and others. Shortly after that, I got involved in developing tools and process instruments that helped agencies take a look at themselves with respect to serving diverse populations. And I’ve been doing it ever since, and watching others develop in a similar way.

Moderator: Thanks, James. Our next speaker will then be Trish Thomas, who is Outreach Project Director for Family Voices. Trish?

Trish Thomas: Yes, I’m Trish Thomas, and I work with Family Voices, which is a national organization that speaks on behalf of children with special health care needs, and I’m also the parent of two children with special health care needs, and because I also live on the Pueblo Indian Reservation, I have been involved, for some time, in looking at services and information that meet the needs of minority populations.

Moderator: Thank you, Trish. Our last but not least speaker is Dr. Richard Aronson, who is the Chief Medical Officer at Maternal and Child Health, Wisconsin Division of Public Health.

Dr. Richard Aronson: Thanks, Wendy. First of all I want to thank both the National Center for Cultural Competence and the MCH bureau for their tremendous support of Wisconsin over the years with respect to cultural and linguistic competence. And I’m here today representing our Title V maternal and child health, children with special health care needs program. I have with me Lorraine Wiszinsky, who is our parent consultant for children with special health care needs, [inaudible] with me as well, and managers who have done a great job over the past decade on working on this issue. We also have the director of our office of Affirmative Action in civil rights compliance for our Department of Health and Family Services sitting in. So it’s really good to be here, this is a journey, and we’re in the midst of that journey and so we look forward to sharing that with you today.

Moderator: The NCCC has prepared a series a questions to facilitate our discussion with questions, and the first set of questions will go to James Mason. So Dr. Mason, can you please explain what your philosophy is regarding cultural competence organizational self-assessments?

Dr. James Mason: Sure. Essentially I start from the bias/ belief that most people want to, that most organizations want to provide quality care, comprehensive services to all the people within their area, or their service area. What I also know is that most of us, as professionals, were not trained to deal with the diversity that America is now experiencing, and so many of us are often caught behind the eighth-ball, so to speak.

As we struggle to get better, one of the things that’s interesting is we’re not always sure if we’re moving in the proper direction and where we still need to grow. So essentially, I believe in taking a fairly safe, non-threatening approach to helping agencies take a look at themselves with respect to underserving diverse populations in their areas.

The goal of the assessment, in most instances, is to identify ways in which agencies can grow. A secondary goal, and we’ve learned this by experience, is that by doing assessments, we often uncover hidden resources and talents within a community that we weren’t aware of.

Another bias/belief that I think that I bring with me, is that there are multiple stakeholders who need to be involved in this process, including organizational administrators and managers, but also line staff, parents, family members, consumers, community and culturally based advocates, and all these need to be involved in a process that is fairly well managed but keeps its eye on the prize, and the prize is enhanced service delivery to diverse populations. If we do it correctly, it becomes a win-win situation, because we improve services to diverse populations and we as professionals feel better about the work we do. And, of course family members, consumers, and advocates will begin to understand and appreciate the work we do better. So I guess my philosophy is one that starts from a fairly benign perspective and tries to build upon that.

Moderator: Thank you, James. James, with the MCH programs, and with a lot of other federally funded programs, you’re hearing a lot about accountability and performance. What are the benefits of self-assessment versus monitoring that has kind of a ring of, you know, someone will have to see you if you’re not performing?

Dr. James Mason: Well, that’s an excellent question. As I mentioned, our approach has been that it’s not punitive or judgmental, and often when we talk about monitoring or hear about monitoring, there’s this ring of sanction if we don’t measure up. That hasn’t been our goal.

One of the things we’ve recognized is that various programs start at different places, and the goal is how to get people, how to get organizations moving more progressively on this cultural competence continuum. Monitoring almost suggests if we don’t measure up, we’re punished. Assessment, on the other hand, in our experience, is conducted to design an intervention that promotes growth in the agency and in the staff, and hopefully also in consumers and family members as well.

Moderator: Thanks, James. In your experience, what have been some of the results of cultural competence organizational self-assessment, you actually named a couple, but if you don’t mind just reiterating?

Dr. James Mason: Well, we’ve done it well and I think we’ve done it well in a lot of instances. One of the certain benefits is greater involvement on behalf of families, communities, and consumers. And as a result, with their participation, there seems to be a greater satisfaction with services, or a greater awareness that services may change to become more satisfactory, that’s one benefit.

Another benefit has been that it’s been empowering for workers who come to the table wanting to serve diverse populations, either because of their own experiences, their own backgrounds, their own knowledge, so they’ve been validated.

It’s also been reassuring for workers who wanted to be comprehensive in their service delivery approaches but didn’t know where to begin. So ultimately what I would suggest is that when we’ve done self-assessment, we’ve brought various members of the community together to focus on improving services to children and families, not only from diverse backgrounds but all children and families, it’s been empowering for workers who have come to this work wanting to be all they can be, and it’s validating for families who, all of a sudden, have a stronger role and voice in how services are provided.

In other instances it’s resulted in more diversification in the work forces. And we’re fortunate that we have Dr. Aronson on the phone today, because I think Milwaukee is kind of a classic example of what can be done, and they take a real panoramic view of changes, while at the same time, recognizing within their organization a great deal of strength, talent, and resources exist that heretofore hadn’t been tapped.

The other benefit is that when we see this permeate an organization so that it doesn’t just apply to workers of color or workers who speak diverse languages, but it actually bubbles up to the top and affects administration, while also trickling down to people who are in line staff positions. The benefits can be multiple, and I think our approach to cultural self-assessment isn’t to impose upon an organization, but to work collaboratively with that organization, so that we both, as a national center grow, but also help that organization grow in ways that are meaningful to that organization, and not so much, or necessarily meaningful to us as a national center.

Moderator: Thank you James, and for those of you who are interested in looking at the actual tools, please get in touch with NCCC, but we thought the discussion today would encompass prospects and outcomes.

Moderator: James, do you have any recommendations for agencies or organizations that might be thinking about doing a cultural competence organizational self-assessment? What do they have to consider in terms of preparing for it, mobilizing resources, finances, and other variables?

Dr. James Mason: Well, one of the things that’s important for an organization to consider is are they going to comprise a task group, or do they have a task group in place that’s empowered to do this work. And that task group should not only be comprised of, let’s say line staff, but should also have some management personnel, administrative personnel, who bring with them some clout, some influence, and some resources, and can go back to management and explain to them what’s happening and why.

Throughout the whole process, however, everyone within this task group needs to be explaining to the rest of the personnel within the organization why this is being done, how it’s going to be done, how it’s not going to be threatening, how it’s going to be beneficial, and that’s an ongoing task. It’s also an opportunity to reach out to consumer organizations, family member organizations, community-based organizations, who also have on their agendas to improve services to populations they care about as well.

I would also suggest to be prepared for a process that isn’t always smooth, so it isn’t a bad idea to consider outside facilitation or bringing someone aboard on the organization who has a strong facilitation field. What we found is that people bring with them a lot of passion on this topic, and often that passion may be expressed in raw form and can be considered abrasive at times, or off-putting at times, so it’s going to be important that this process is facilitated strongly.

Something you said earlier that I think is absolutely critical, Diana, and that is that the process is probably as important as the product, and what I mean by that, is that your approach to facilitating the work is as important as any tool that’s selected. And I think that one of our lessons learned is to really pay attention to the process, the logistics of the process, and that would include such things as making sure that we have interpreters, linguistic services that allow everyone to participate, that we’ve oriented people early on so they’re not blindsided by anything that we’re doing, and that we keep our eyes, again, on the prize, and that’s to enhance services, certainly to diverse populations, but to everyone that we’re trying to serve effectively while making the work place a better place for diverse and all other workers in that organization.

Moderator: Thanks so much, James. We’re going to move now to Trish Thomas, and Trish, I have the first question for you. Can you briefly describe the collaboration between New Mexico’s Children with Special Health Care Needs Program, also known as Children’s Medical Services, and Family Voices, and other family serving agencies or programs?

Trish Thomas: We here in New Mexico have pulled together an MCH collaborative group, and that’s all of the groups in the state who receive MCH funding, of which Family Voices, Title V, and other agencies are, and that group has come together, going on three years now, and so together we have meetings once a month. We look at how we can collaborate within those agencies so that the individuals that we’re serving, children and families with special health care needs, get the information that they need and so that services are not duplicated.

So the agencies are providing information to those groups, and it’s been a longstanding collaboration between all those agencies, and it’s been very effective for us.

Moderator: Thank you, and Trish, as one of the national staff for Family Voices, which really tries to advocate for families, provide training, technical assistance and information, particularly around policy kinds of issues, how does Family Voices become involved in the whole area of cultural competence organizational self-assessment?

Trish Thomas: That came about again, looking at some of the needs that some of the families have, as well as the agencies, and so meetings, again with Title V, took place, and it appeared that the next step needed would be some type of assessment, and as we looked over the information once again, it appeared that it would be a cultural competence self-assessment.

Moderator: Thank you.

Moderator: Trish?

Trish Thomas: Yes?

Moderator: I know, most people don’t know, but you did participate greatly in the cultural competence organizational self-assessment that took place with Children’s Medical Services with the National Center for Cultural Competence as facilitator, so bearing that in mind, can you tell me what the assessment process was like for you as well as for the families that you brought into the process?

Trish Thomas: First of all, we were very excited as a state, and with the families involved, that this process was going to happen, because we saw it as a very positive step. And I was very happy to be a part of it, as well as other family members from other groups that were brought in to help facilitate.

And looking at the assessment I felt that it was a very good assessment that would help move our state forward in the area of cultural competence as well as helping families better understand the services that were being provided through Title V.

And it was a process, networking with the various agencies to become part of the assessment, not the agencies themselves, but New Mexico decided to do the whole state, so it was a whole process, like James said, we learned within the process, as we went along, incorporating and pulling in the families, the families are always at the table and having input at the various levels, which is very key, I think, in bringing in the other families who are actually part of the assessment.

Moderator: Trish, I think your organization as well as another family organization helped to facilitate and provided some stipends in order for families to attend focus groups?

Trish Thomas: That’s true and I think that was one way that we were able to validate family participation and help these families, actually with money for babysitting and/or travel to and from the focus group sites. Families were very appreciative of that, they really felt that not only were they being validated monetarily, but they were being validated verbally and in other ways by being provided additional information when they requested it.

It was just a really good process. Again, I think the families who participated in the groups, myself and the other facilitators had worked within the state, so we had dealt before with the various families who have children with special health care needs, if the families didn’t know us, someone else did, and what we did to help better facilitate these families is that we looked at bringing in additional community leaders who were already respected and trusted within the communities.

Moderator: Thank you, and James had talked about having a facilitator for this process. NCCC was an outside facilitator for the process, and what are some of the pros and cons that you can think of in terms of having someone not affiliated with the organization help to conduct the self-assessment?

Trish Thomas: I’m going to start with the pro’s, I went ahead and went to the sites identified and made contacts within those communities of individuals who were respected, again, and had the expertise and could pull families into those focus groups. Because I knew the National Center, and because families sometimes feel that they are more open to accepting someone not known to them to come in and help with the assessment, they felt they could more readily express themselves. And that was very good, because then they could come in, and they would leave, and they didn’t live here in the state.

A con was that we had to build up the trust with them very fast, and knowing that we trusted them, and because, I think, as I say, the other parent facilitators and myself have been in this business for a while and worked with the various programs around the state, and a lot with children’s medical services, they were open to really taking our word that these were good people that were coming in and it was going to be a positive experience.

Moderator: Trish, can you tell me, as you look back and think about some of the things that you did and that the other individuals who assisted with gathering or bringing in the family members, when you think of the things that you did, what are some things that you might suggest that agencies who are looking to conduct a similar process can do to ensure participation?

Trish Thomas: Yes, I think bringing in the families right at the beginning and either identifying those family members, like we were identified as being family members to help assist, and having them there in the beginning, for the planning and all of what is happening, every step. Plus, what the other facilitator and I did, was we called, again, once the communities were identified, find those key community people who could help us, because we again, don’t know every community in the state, they were able to assist us in finding areas where families felt comfortable sharing, they knew areas where families may not want to come and share. And some of them were very adamant about not having the focus group in certain areas. And so having those community members along with the identified family facilitators really helped this assessment along and made it a positive event.

This is not to say that we didn’t come upon some snags. I think, there was good and bad, and it was getting started, and we learned from our mistakes and we moved forward.

Moderator: Trish, in your opinion, what were some of the outcomes of the organizational self-assessment process in terms of systems development, in terms of family participation?

Trish Thomas: I think, I’m going to come from a family perspective. With families, it gave them better information regarding services available to children with special health care needs, they learned more about Title V as well as other services in the state, the collaborative process of Title V, and to me some of the families, for the first time, kind of saw how it was interconnected with services for their children with special health care needs.

And being able to provide input that would have a definite impact on them regarding services, and looking at system changes, because again, they are the recipients of the services, they were able to provide information that was going to make a positive change for them. And I think they saw that as a plus and were very open to providing information.

Again, these families who came in and shared information were willing to be contacted again in the future if, in fact, they needed some sort of new information, to get additional input. So at various levels, it started building a kind of network of families within the state that Title V and other agencies then could call on.

Moderator: Trish, I think within your state of New Mexico, you’ve had activities somewhat decentralized into health districts, so some of the families, then, are working within their communities along with the Health Department on cultural competence and other issues, right?

Trish Thomas: Yes, they are pulling in those families and those families, in turn, appear to be mentoring other families into a process that they’ve gone through, so it’s had a very positive effect, and somewhat of a ripple effect, as the families who were brought in provided information and shared that support, and it’s just spreading out. It’s been, I think, very positive, and I think the families still, at least some of them, feel very good about knowing that the input they gave made a difference. They feel it’s made a difference.

Moderator: Thank you, Trish, and now we’ll talk with Dr. Aronson, and I’ll call you Dick, okay, because that’s what I’m used to calling you!

How did the state of Wisconsin and the Milwaukee Department of Health decide to even conduct a cultural competence organizational self-assessment?

Dr. Aronson: Okay, and I’ll call you Diana. Again, I have with me Lorraine Wiszinski, who’s our parent consultant, and I want to be sure to tell people to think of questions to ask her after we end this part of the session.

Basically Diana, this is a journey toward cultural competence and cultural proficiency. It’s an ideal. And in 1993, we expanded our MCH program advisory committee to about 40 people, it had been about 10 or 15 people, we diversified it, and we started to think of different ways to make sure that the new people on the committee would feel comfortable an validated and affirmed, and that process still goes on.

In 1994, with the help of the MCH advisory committee, we as a Title V program for Wisconsin, established five guiding principles, which would apply to all of the programs we support and work within in the state of Wisconsin. And those five guiding principles are 1) family-centered care, 2) community-wide leadership, 3) resiliency and a focus on strength, 4) outreach, and then 5) cultural and linguistic competence. So we established those five guiding principles back in 1993, and then in 1994, when we arranged for how we would allocate our MCH block grant dollars for a cycle of about five years, we developed requests for proposals that asked each of the applicants to speak to each of these, to the extent that they would apply those five guiding principles to their projects.

In 1996, we were very excited to establish contact with the National Center for Cultural Competence. Meanwhile, we had been working with Milwaukee for several years with respect to infant mortality disparities and other major health issues in Milwaukee, and we were very aware that, in spite of having a lot of programs and services and policies, and so on in Milwaukee, something was missing, people were not talking about the issues that really mattered and that were getting in the way of being able to work together.

Fortunately, we had some partners at the Milwaukee Health Department who were very interested in taking a look at this issue, and that’s the time, 1996, when we actually established our initial connection with the Milwaukee Health Department in terms of being one of the first projects that the National Center for Cultural Competence offered assistance to with respect to organizational self-assessment.

Then in 1998, two years after that, we brought together a very diverse group of people from around the state and had a two-day workshop that was really phenomenal. The purpose of it was to come together to develop a set of recommendations to us at the Title V program to implement cultural competence throughout our MCH and children with special health care needs program.

So we had that conference, and we had the National Center for Cultural Competence come in, and Tawara came in, and the Milwaukee Health Department had a strong presence at that meeting, and we did release a booklet, in 1999, which we widely circulated, it’s known as the cloud booklet because there’s some clouds on the cover. We also—before we ran out of money and we couldn’t print it in color, it was known as the rainbow booklet, but after we lost the money, we had to just have regular black and white cover, and it’s called the cloud booklet.

Moderator: Alright, Dick, rub it in.

Dr. Richard Aronson: So that’s a start for the first question.

Moderator: Just for a little clarity, when you talked about allocation of MCH block grant funds and having some requirements in your proposals or your calls for grants, are you going to talk about what types of projects?

Dr. Richard Aronson: Well these are all the projects that we fund, all the local health departments, also we have some very exciting state-wide projects in genetics, and a Children’s Health Alliance of Wisconsin, we have a series of home visiting projects that we initiated a couple of years ago throughout the state to prevent child abuse and neglect, and basically what we have done is, in our request for proposals, we make sure that the reviewers of the proposals are diverse, that includes families and people from diverse backgrounds and diverse disciplines. We organized the scoring on our request for proposals to reflect the five guiding principles.

Other impacts, kind of getting to the second question—one, I think, kind of stepping back and looking at the larger picture, is that both the partnership that we developed with Milwaukee and with organizational self-assessment there as well as other state-wide activities, really, really got us to truly understand and define health in a very specific way for our programs. And there are kind of two basic elements to that definition of health that we use wherever we go.

The first is, that the essential purpose of maternal and child health does not lie just in the prevention of disease and illness and morbidity and mortality, and reducing risk, but more importantly, probably, is a way to foster strength and capacity and resiliency in families and communities. And that community change is a key factor in improving the health of children and families. So we were able to really get that concept out much more strongly, because when you start to look at cultural competence and start to look within, you realize how important it is to have a positive approach, and one woman described it as assets and strengths rather than just deficits, so that people feel much more affirmed and they feel that they matter.

The second key aspect of our definition of health that came out of all of this was the key fact, which research is now showing more and more, that the extent to which we respect each other, not only among the families that we serve, but also among ourselves, within our organizations, the extent to which we treat each other with respect and dignity and honor the culture from which each person comes, that has a direct impact on our health.

And I know that when I went to medical school they told us, “Physician, heal thyself.” The key here is that in order to be able to serve others, we have to have the courage to look inward, and look at our own health and well-being, and see how we can improve and enhance that. And that’s why organizational self-assessment is so powerful, because it not only enables us to look within our own, personal journey, but also at that of the organization. And when you do that, you realize that you’re on this path, and you’re then better able to see how that might affect services. Because when an organization is unhealthy, the services that it provides to families is going to be unhealthy. And it works the other way around as well.

So the cultural competence journey here for us has had a huge influence on everything that we do, really, a very wide range. And beside the request for proposals that I mentioned, there are a number of other things that have occurred, we are modifying our risk-assessment tools to become more strength- and resiliency-based, we’ve established extremely strong collaborations with our Healthy Start Projects, we have two Healthy Start Projects for reducing infant mortality, one of which is in Milwaukee, the other is involved in the Native American community, and we have learned a great deal from the Healthy Start Project.

The one in Milwaukee works closely as well with the Milwaukee Health Department; we have brought Milwaukee’s Healthy Start Project and the Native American Healthy Start Project into a lot of what we do.

Other changes that have occurred, we were able to hire a paid consultant within our organization, that took years to work through the bureaucracy to do it but we finally did it, which was great. We try to have, when we give presentations and we give talks, when we have workshops, we try to balance it—we try to bring on a parent and a community person as a team member in our presentations.

But what I really want to stress is that this is a learning process, and I do have a quote about this one, on learning. Actually, I have a quote from Gandhi that I wanted to use today, which is “We must become the change that we want to see.” So before we can start change in our world, we need to change ourselves.

And the other thing we have found is language. We try to emphasize in all of our gatherings and work for people to drop the titles before their names, and that’s why it’s good that you’re calling me by my first name, which is great—drop their titles and degrees and stop using the jargon and rhetoric of our own professions and our own disciplines. And we try, in our MCH advisory committee, for example, to practice that, so that the parents and the community leaders and advocates can feel just as welcome as the traditional stakeholders.

So language is very important, and we find this—the extent to which children treat each other well, how families treat their children, how communities honor their children and the cultures that they represent, all of this has a great impact on health.

And some of the things, a few of the other things that we are learning or have learned about are the following: first of all, it’s not very helpful to go in there giving out a message that an organization is biased or not culturally competent. We have to go in there, not with an “us versus them,” but an “we’re all in this together, we’re all on this journey,” we all are trying to start to learn to do better, that’s really important.

Another key aspect that we’ve learned from this self-assessment is that there is more heterogeneity within cultures than between cultures, so that to honor the uniqueness of each person within a culture, it helps to stereotype, label and judge less, although it’s still a major challenge. So honoring the uniqueness of every individual and affirming the uniqueness of all people and at the same time, acknowledging how important a role culture plays in everyone’s life.

Another aspect is that we’ve learned not just to talk about issues affecting African-Americans or Native Americans, or certain racial groups or ethnic groups, but to culture-assess everybody. For example, a home visitor recently went into one of our homes, in one of our home visiting programs, and it was in November, and the family had a deer in the house that had just arrived, the family had just captured the deer, it had been brought into the house, and this was a great prize. And the home visitor was from the city, from, I think Milwaukee or Chicago or somewhere, and, you know, didn’t realize how important deer hunting is to that particular culture. So that is an example of a great learning experience, so we try to do that.

Another good learning experience is our genetics program, by the way, we developed and organizational self-assessment tool for all of the guiding principles, and we started using that in the year 2000, so we give this self-assessment tool to everybody and encourage them to fill it out, and we base the cultural competence questions pretty much on the guidance that we got from James and Tawara and Diana, from both the Center and the Bureau.

And what we’ve been doing, our staff meets with the organizations that we support and we go over this. And we’ve found out some fascinating things.

For example, we find it very positive when an organization rates itself poorly on its self-assessment, because that means they have the courage to admit that it is a journey and on a continuum. For example, let me give you an example. For one of our projects in genetics, we had a self-assessment which said the following: “Acknowledges and collaborates with community-based resources such as culture-specific medical practices, spiritual healing, and traditional beliefs.” And the genetics people, the genetics project, said the following: “We view this as an inappropriate goal.” Okay? But they filled that in, and that’s really positive.

Dr. Richard Aronson: There is an inextricable link between family-centered care and cultural and linguistic competence, it is really very important, and what’s been really exciting is to see parents, who have gone through, well, an example is, one parent of four children who we brought on to the MCH Advisory Committee in 1993 and 1994, he had one child who recently passed away who had severe special needs.

That parent went on to work for the Milwaukee Healthy Start program, it’s a community-based organization called the Milwaukee Healthy Infants Project, she then went on to work for an agency in Milwaukee that advocates the welfare reform to make sure that child care and transportation are accounted for, and she’s become a real systems mover, and actually became the co-chair of our MCH Advisory Committee.

So the transformation that people have been undergoing is a source of tremendous inspiration, and we try to celebrate that as much as we can. Because by the way, this work is really hard work, and it can be very frustrating, and very confusing, and very disappointing at times, in Milwaukee there are major racial problems and issues deeply-rooted that go back many, many years and decades. It’s impossible to solve that, obviously, overnight, that’s why it’s very important that we celebrate little things that are really not little things, but both individual and organizational change.

I just spoke with the head of the Health Department in Milwaukee, it’s been six years since they started this in Milwaukee in the Health Department, and I asked them, how do you think things have gone since this started? And I guess what really pleased me was his response, because it was so honest. He said, “Frankly, we are still at the beginning. I don’t think we have made meaningful change in the day-to-day operations as it applies to services.”

So at the same time, he affirmed the self-assessment process and said that at least now, issues which had not been talked about before, which had been driven under the table but were very real, were at least on the surface and people were starting to acknowledge and talk more openly about them.

So if we can somehow foster an environment where people can at least feel more comfortable talking about delicate and fragile issues, that’s going to go a long way toward building trust. And you’ve got to have trust to move toward cultural competence.

Moderator: Dick, thanks so much, you’ve done such a great job with outlining all the wonderful outcomes and the very positive experiences that the state of Wisconsin has had as a result of dealing with cultural competence and organizational self-assessment. But I was wondering if it wouldn’t be too painful to go back and revisit some of the possible obstacles that might have been encountered as the process of cultural competence and organizational self-assessment was undertaken?

Dr. Richard Aronson: I think one of the obstacles is people don’t think it applies to them because they live in all-white, homogeneous communities. They don’t think that cultural competence involves them. So that’s why we like so much the definition, and we try to use the definition from the National Center, because it really goes beyond that. But that’s an initial barrier.

Another one is that people think that they’re already doing it, and they’re tired of it, and they think it just means going to one training or two trainings per year, that’s a major barrier.

Another one is that there are deeply entrenched ways of doing business that are deeply woven into the bureaucracy. For example, when we have the Native American tribal chairs come to our department for a meeting on how to enhance partnership between the state health department and the Indian tribes in the state, we failed to serve them a meal at the end of the meeting, which ended at noon.

And the main reason, two reasons, first of all, we didn’t fully appreciate how important a meal is in anything that Native American people do when they get together, and secondly, the bureaucracy, at the time, of getting a meal, actually getting a meal ordered and brought into the building for a meeting involved so much paperwork and was so burdensome, that it took a heroic effort at the time. Our staff has been great at that, and we’re trying to change things around, we’re working on it, but you do have organizational obstacles.

Another one is that when you think about an issue, that first instinct is not to bring in all the stakeholders. So for example, when we identify an issue that’s a problem, and we start a discussion, a conversation, and start to plan it, we don’t bring family members and people of diverse backgrounds into the conversation from the start. And that’s very bad, because then they feel like they’re not part of the process. So that’s been another obstacle. So that’s a few of them, Wendy, but there are a lot more.

I think another one that we’ve learned is that every culture is ethnocentric, okay? It’s important to realize that we all, no matter what culture we come from, including minority cultures, we all are ethnocentric. So we all need to move from our ethnocentricity to being open, and that involves acknowledging that our views are ethnocentric.

One thing that we frequently do in our discussions is we go around the room and ask people, when they were children, how their parents approached the common cold. And we end up with like two-dozen answers from like 25 people, because it’s so different, a lot of it depending on the particular country of origin of their ancestors, whether they grew up in the city or the country, all kinds of things. So that kind of—recognizing that diversity is key.

And then I think the other thing, that James said at the very start of this, is that while the beauty of this country is the diversity that we have and the potential for people to truly honor each other and learn from each other, we are not equipped, we are not trained to do that. So we all are on this learning curve and we have to admit our own errors and mistakes and confusion, and that’s often difficult to do, especially if you’re trained that, as a doctor, you know everything.

Moderator: This is the last question before we open up for participant questions, but you’ve done such a really great job of outlining the positive and identifying the negatives, that I’m wondering what were some of the things that you did, or strategies and techniques that were employed to manage and overcome the obstacles and barriers that you just told us about?

Dr. Richard Aronson: I think one thing is that we always emphasize in our discussions that every person has a culture, no matter what particular racial background they may be from that there are all kinds of cultures. For example in Milwaukee, at the Milwaukee Health Department, some people went to the director of the department and they said, why isn’t this issue addressing the concerns of gay people?

And that turned out to be an area of conflict. Some people within the Milwaukee Health Department felt that the diversity effort was not inclusive of that group. So, I think the key here is to try to foster an inclusive environment. And collaboration, I talked a little bit about language being very important, in terms of not using all of those terms and acronyms, those thousands of acronyms.

Another key thing is the term “expert,” we try to emphasize that everybody is an expert and that parents, really, are the experts. They have their doctorate in perseverance, and we all know that, so everybody is an expert, that’s another thing we try to emphasize.

And we try to emphasize the point that you start where you are. And that’s fine, and there’s no judgement here, and you try to affirm organizations that have the courage to say that they don’t have written policies in place, they don’t have questions, when they interview people for jobs, they don’t have questions that relate to cultural issues and understanding cultural issues, and they don’t have ways to incorporate spiritual healing practices. That’s all good, so we try to affirm that and we try to be really humble ourselves in admitting how far we have to go. We in our own division of public health, our own bureau, within our own programs in Title V ourselves, so that’s another thing.

And we try to emphasize that this is about, not necessarily liking each other or agreeing with each other, but a matter of respecting and listening to each other, and there’s a key difference between that, between—we don’t expect people to all like each other, but we do expect to respect each other, and what we try to do is always begin the dialogue and conversation by going back to what brings us together, what is our common ground rather than what separates us.

We always try to emphasize the fact that 99.9 percent of the human genome is the same, and we always try to go back to collaboration and Martin Luther King when he said that we must learn to live together as brothers and sisters or we shall perish together as fools. So this idea that we all share in this responsibility to come together in authentic community, and we use MCH not to stand for just maternal and child health but to stand for making community happen, and we try to, basically, build civic engagement and social support and service as being vital for promoting the health of children and families. When kids feel that they matter and they feel they’re important, they’re more likely to be healthy, physically as well as mentally and spiritually.

Moderator: Thank you so much. At this point, we’re going to move to the structured participant question and answer session, meaning that this is the time for the call operator to give out the instructions again, and participants, get ready with your questions.

Joyce Jordan: My name is Joyce Jordan, I’m a physician at a college health center and the issue of cultural competency is very new to the college health organizations. I specifically would like to address my question to James Mason. How would you suggest an organization like a college health center start to do an organizational assessment?

James Mason: I’d try to create a groundswell at first, try to get some people to join you and understand the importance of it, and that would probably be a multiple levels.

I would also look at some of the work that our center has done, it’s good to hear Dr. Aronson and Trish Thomas talk about their experiences and the benefits. One of the things that I found to be an impetus for organizational change is that organizational administrators have to understand why it’s in their best interest, and so I’d try to create a groundswell around the potential win-win, how it benefits your organization, how it benefits individuals within your organization, and start from there.

And I would look for some sympathetic ears, you’re not going to convert everyone all at once, and the thing that Dr. Aronson said is also important, is to be prepared for the bumps in the road, those are inevitable. But it’s easier to do when you have a few people joining you, supporting you, and once that groundswell is created, I think it will take on its own momentum.

Tawara Goode: And Joyce, there is a document up on the NCCC website about getting started, so you may want to take a look at that, it has some good ideas for people who are just beginning to consider cultural and linguistic competence.

Joyce Johnson: Okay, thank you very much.

Dr. Richard Aronson: Diana?

Diana: Yes?

Dr. Richard Aronson: This is Dick, I’d like to have Lorraine give a few thoughts from her perspective as a parent consultant, I wanted to make sure to bring her into our conversation since there are no questions right now.

Diana: Sure, Lorraine?

Lorraine: I’m not sure exactly what is most important, I think that one of the things that has been a struggle for my role as a parent consultant is ensuring that I’m presenting a broader parent perspective from all different diverse cultures, and I think it’s important to just bring about the fact that as you’re looking at how to represent a broader perspective, to make sure you’re connecting with key leaders.

I had the opportunity, when I first started, to go to Families Helping Families gathering, but it’s the combined training that they do with the Healthy Start program here in Wisconsin, so I got to meet some of the key leaders from the Native American culture, African-American culture, and that helped, to be able to hear some different perspectives and to be able to always, continually, look at different things outside of myself and my background and how it might impact families in different ways.

I just think that’s kind of important, as we think about how often times we have that token parent who represents so many different views, but we need to acknowledge that there needs to be a whole bunch of different people to bring those views in and make sure that they’re able to do that in an efficient way to make sure that we’re really looking at diverse cultures.

And the other thing I’d like to say is one of the things that I think has been very important for me is that at any kind of training event or anything that we’ve done within our program, we’ve really tried to model how to bring people together, which is one of the reasons Dick asked me to be part of this, so that we can always be looking at, parents and professionals both, talking about issues and thinking about that and how to always bring a family to the table to bring about their perspective as well.

Moderator: Thank you, are there any more questions or comments from the audience?

Trish Thomas: This is Trish. I just wanted to add how important it is when talking about cultural competence that you provide the definition. When I talk about cultural competence, I talk about it in a very holistic manner, and let them know that, I know some people, when they first heard it, they immediately thought of, or flipped to, race and ethnicity. But when we talked about looking at it in a very holistic manner, and it included a wide variety of individuals that represented the geographic, socio-economic, as well as cultural and ethnic backgrounds, it just sounds better for them. And families, also feel more comfortable and included, because it’s very broad, pulling in everybody.

Operator: We have a couple of questions from the field, the next person in the queue is Elizabeth Diaz.

Elizabeth Diaz: In organizing, I would imagine that what you’re suggesting is when you’re organizing a group of people who can join you in your mission, and this is either to Dr. Mason or Dr. Aronson, do you want to organize individuals who are from different backgrounds and different religions? I mean ideally, that is probably how I would see a group that would make some changes, is that how you suggest that maybe a committee be formed?

Dr. Richard Aronson: Yes, exactly, definitely. It’s really important that a committee within your organization represents the diverse racial and ethnic backgrounds, not only of the people in the organization, but of the people who are being served by that organization.

And secondly, that some attention be paid to ensure that the initial committee include people from all different types of work within your organization so that you have people who are doing program assistance work and clerical type of work as well as people who are in more consulting and management roles, try to get a wide spectrum of people as much as possible.

And as James says, it’s just amazing that when you start to look around and start to use the language that we’ve been using today, you find that a lot more people are interested in this than you might think at first. And that’s one of the pleasant surprises about this.

But I think the organizations that we have found that do the best are the ones where a committee starts up, not necessarily in a formal way, but kind of like just an informal group of people getting together to look at the issue and talk about it themselves and start to become more aware and then go from there. And if you don’t have the buy-in from the president or the chief CEO or commissioner at the very start, that’s okay, that hopefully will happen as time goes on.

And as James said, it’s a win-win situation, and the National Center has documented this very well in its paper called “The Rationale for Culturally Competent Organizations.” It’s definitely in the economic self-interest of health care organizations to work towards cultural competence and secondly, specifically with respect to physicians, it’s very clear that physicians who communicate more clearly with their patients are much less likely to get sued. So there are some definite self-interest issues that are worth emphasizing.

Moderator: Thanks, James, did you want to address Elizabeth’s question?

James Mason: Yes, I was just fascinated listening to Dick, I agree with Dick an awful lot, and Dick said something earlier, and I think this is my experience when I worked in New Mexico, was that there is so much difference within any cultural group or racial group, and that often those differences are so easy for us to see. I think what’s important, however, is for us to focus on what we have in common and start there. And I’m really reminded of the parent or family member consumer movement, and if you watch how they’ve worked over the years, they’re very, very diverse individuals, but they keep their eye on improving services for families.

And when I think about Elizabeth’s question, as you bring people together, and the differences will be apparent in terms of occupation, their own cultural background, their own familiarity, it’s important to remind people why we’re here, why we’re together, and the ultimate goal is to provide services, and then we can start to think about our own personal interests.

But I think Dick was very, very clear as to how this could get started, and if you don’t get buy-in from the top, initially, don’t panic. If you don’t get buy-in from other groups initially, don’t panic. I think they will come around, and when we started in Milwaukee, there was no guarantee or no indication that it would go as far as it did, so I agree with Dick, and I also think we should look at the parent movement and see how they’ve been able to bridge differences and overcome differences while maintaining focus on their commonalties.

Elizabeth: I think that’s it. I asked that question because we recently went through an assessment at the building level where I work and one of the questions they asked was how diverse do you feel? The response I gave, I actually got the question, was there isn’t as much of a diverse population in the management level.

Moderator: Elizabeth, there’s another call waiting and we want to try and get that question in, please.

Elizabeth: Okay.

Operator: The next question comes from Magda Garcia.

Magda Garcia: Yes, I would like to talk a little bit more about the administration. I work with health plans and a lot of them really are interested, probably because of the legal problems that they may encounter. They are interested, of course, in the health of the community, but they would probably want to know more about the economic side to get them more involved. If you just talk about regulatory, they may never see it as something like a long-term commitment, becoming culturally competent. But what do you recommend or what have you found along the way that would be useful when you’re working with health plans?

Dr. Richard Aronson: This is Dick, I’ll just jump in on that. That’s a really, really good question. Wisconsin was one of the first states to have managed care and Medicaid-managed care organizations almost 20 years ago, especially in Milwaukee. We were able to get the chief executive officer of the largest HMO in Milwaukee to engage in a conference back in 1994 called “Common Ground” which is based on a strategy called Future Search, which is a way of building collaboration among multiple stakeholders and getting the whole system in the room.

And we had a number of families at that conference who, very eloquently, described the very difficult experiences that they had in navigating their way through the HMO system. And their authenticity, the power of their experiences, of sharing that in that type of setting, was very compelling for this chief executive officer of the HMO as well as for our state Medicaid director, who was also at that conference. And that HMO subsequently went on to develop a partnership with the Healthy Start Project, which was a community-based organization, and started doing some outreach efforts and things of that nature.

And again, I don’t pretend to have any answers to this, and it is not easy at all, but if you can find a few folks in the large health care organization who share the interest and the ideas that we discussed today, and engage them in a dialogue where you get a diverse group of people in the room, and you hear from people, from families who’ve had to struggle.

One of the greatest things about people is that we have this thing called intuition, and we can intuit, and so that when we make a telephone call to a doctor’s office, we can immediately intuit, not by what the person says, but how that person says it, whether we’re welcomed or affirmed. The same thing happens when you enter a health care clinic or office. And I think just hearing from parents about their experiences of not feeling welcomed and affirmed, and doing that in a setting that’s safe and comfortable and there can be some trust can start to lead toward change. But it is not easy and you’ve identified a very important issue.

Tawara Goode: Magda, I’m going to say this really quickly, because we are coming up, quickly, on the 4:30 hour. I think if you look at policy brief one from our website, in publications, several things come to mind to share information with your health plans. One is that they need to pay attention to the changing and emerging demographic trends. I think that is really key and critical in terms of what their patient population is comprised of.

The other is the whole issue that came up earlier, with regard to liability. Decreasing liability indeed decreases cost, and lastly, if they provide care that is accessible and acceptable, that they will increase their market share. But we can talk with you about that later if you give us a call.

There are other managed care organizations that have implemented cultural competency kinds of activities, so we can share that with you as well.

Magda Garcia: Thank you.

Moderator: At this point, do we want to talk about the evaluations?

NCCC: Yes, first of all, I want to thank you all for joining us this afternoon, we’re delighted that so many people had an interest in this topic, but what we would really like in return is for you to provide us with feedback about the call, about the topic, and a little bit of information about yourself so we can have that for recording purposes.

You will get an e-mail from us with an evaluation form, and we would very, very much appreciate it if you would take that, print it out, fill it out, and fax it back to us so that we can, for our future calls, know things that we might do differently, and also to get your feedback about this one.

Diana: And also, for those of you who did not have an opportunity to ask questions, please feel free to call NCCC, call Wendy.

Wendy: Here’s what we’d like, for people who didn’t get the opportunity to pose a question, if they would e-mail it to us at cultural@georgetown.edu, it would probably be a little more efficient and we could probably manage the flow of questions a little bit better.

The same thing is true for those folks who did not receive materials, if you didn’t go back and visit the website, you should do that, because that’s where the majority of the materials are, as well as the ones that came with the e-mail when I gave you the instructions on how to get on this call. If you didn’t receive it, e-mail us and we’ll be able to handle this a little bit more smoothly in that way.

Diana: Thank you, Wendy.

Wendy: You’re welcome. Now, thanks so much, everybody, for your time, your patience, your questions, for your ears, for tuning in with us this afternoon, and we’re looking forward to having the opportunity to share more information with you in the upcoming months. So check in or patch in to the website as the case may be, and you’ll be able to see when the next two calls will be.

Diana: I’d like to thank all of our speakers, NCCC, and all of you on behalf of the Maternal and Child Health Bureau.

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