R.T. Cultural and Linguistic Competence Tool Kit

Introduction to Cultural and Linguistic Competence

What is cultural and linguistic competence? 

Cultural CompetenceAs defined by the United States Department of Health and Human Services Office of Minority Health, cultural and linguistic competence is a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals that enables effective work in cross-cultural situations. "Culture" refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups. "Competence" implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors and needs presented by consumers and their communities. Why is it important to be culturally competent?

As health care providers, being mindful of the beliefs of your patient helps in establishing good communication and gains the patient's confidence in order to effectively perform the procedure.

By clearing potential misunderstandings, the radiologic technologist avoids problems that may interfere with the acquisition of a good image and cause unnecessary exposure to radiation. Additionally, being culturally competent helps the health care provider in eliciting vital information from a patient who may be reluctant to communicate for fear of offending the caregiver.

Respect for the patient's beliefs helps in the mental aspects of the process of recovery from illness.

What about linguistic competence? 

As the percentage of patients who do not speak English or who speak English as a second language continues to grow, health care providers will encounter individuals with limited proficiency in English. What most people do not know is that providing assistance for these individuals has been required since 1964 as part of the Federal Civil Rights Act.

Why don't they just learn English? 

It is entirely possible that the patient has learned English, but as in any kind of endeavor, people learn at a different pace from one another. A person may in fact know enough to handle circumstances one normally faces on a daily basis but may not be able to communicate detailed symptoms or understand medical terms.

Another surprising piece of information that not many people realize is that the United States has never passed a law declaring an official language so while English may be the most widely spoken language, it is not the official national language. States may or may not have English as an official language and some have other languages in addition to English as the official language in the state.

Finally, a person may know English but revert to speaking his or her native language after suffering a neurological injury or an illness like Alzheimer's.


Legal Requirements 

National Standards on Culturally and Linguistically Appropriate Services (CLAS)

These standards were developed by the Office of Minority Health (OMH). They are primarily directed to health care organizations. There are 14 total standards. Standard 4, 5, 6 and 7 are federally mandated for health care organizations that receive federal funds. A complete list of the CLAS Standards may be found at the Office of Minority Health website.

Standard 4
Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.

Standard 5
Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

Standard 6
Health care organizations must assure the competence of language assistance provided to limited English-proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).

Standard 7
Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

Executive Order 13166

Executive Order 13166 was issued August 11, 2000, and published in the Federal Register on August 16, 2000. The order mandated that each federal agency examine the services it provides and develop and implement a system by which limited English proficient (LEP) persons can meaningfully access those services consistent with the fundamental mission of the agency. The order also required each federal agency work to ensure that recipients of federal financial assistance provide meaningful access to their LEP applicants and beneficiaries.

Compliance requirements are broad. All federal, state and local government agencies as well as any entity that received federal money, public or private, are required to implement this executive order. Given the fact that most health care facilities accept patients with Medicare, with many facilities also accepting Medicaid patients, practically every health care provider and every facility is affected by this requirement.

You may find a copy of Executive Order 13166 in the Federal Register or read the text of the order below:

Text of Executive Order 13166





By the authority vested in me as President by the Constitution and the laws of the United States of America, and to improve access to federally conducted and federally assisted programs and activities for persons who, as a result of national origin, are limited in their English proficiency (LEP), it is hereby ordered as follows:

Section 1. Goals.

The Federal Government provides and funds an array of services that can be made accessible to otherwise eligible persons who are not proficient in the English language. The Federal Government is committed to improving the accessibility of these services to eligible LEP persons, a goal that reinforces its equally important commitment to promoting programs and activities designed to help individuals learn English. To this end, each Federal agency shall examine the services it provides and develop and implement a system by which LEP persons can meaningfully access those services consistent with, and without unduly burdening, the fundamental mission of the agency. Each Federal agency shall also work to ensure that recipients of Federal financial assistance (recipients) provide meaningful access to their LEP applicants and beneficiaries. To assist the agencies with this endeavor, the Department of Justice has today issued a general guidance document (LEP Guidance), which sets forth the compliance standards that recipients must follow to ensure that the programs and activities they normally provide in English are accessible to LEP persons and thus do not discriminate on the basis of national origin in violation of title VI of the Civil Rights Act of 1964, as amended, and its implementing regulations. As described in the LEP Guidance, recipients must take reasonable steps to ensure meaningful access to their programs and activities by LEP persons.

Sec. 2. Federally Conducted Programs and Activities.

Each Federal agency shall prepare a plan to improve access to its federally conducted programs and activities by eligible LEP persons. Each plan shall be consistent with the standards set forth in the LEPGuidance, and shall include the steps the agency will take to ensure that eligible LEP persons can meaningfully access the agency's programs and activities. Agencies shall develop and begin to implement these plans within 120 days of the date of this order, and shall send copies of their plans to the Department of Justice, which shall serve as the central repository of the agencies' plans.

Sec. 3. Federally Assisted Programs and Activities.

Each agency providing Federal financial assistance shall draft title VI guidance specifically tailored to its recipients that is consistent with the LEP Guidance issued by the Department of Justice. This agency-specific guidance shall detail how the general standards established in the LEP Guidance will be applied to the agency's recipients. The agency-specific guidance shall take into account the types of services provided by the recipients, the individuals served by the recipients, and other factors set out in the LEP Guidance.

Agencies that already have developed title VI guidance that the Department of Justice determines is consistent with the LEP Guidance shall examine their existing guidance, as well as their programs and activities, to determine if additional guidance is necessary to comply with this order. The Department of Justice shall consult with the agencies in creating their guidance and, within 120 days of the date of this order, each agency shall submit its specific guidance to the Department of Justice for review and approval. Following approval by the Department of Justice, each agency shall publish its guidance document in the Federal Register for public comment.

Sec. 4. Consultations.

In carrying out this order, agencies shall ensure that stakeholders, such as LEP persons and their representative organizations, recipients, and other appropriate individuals or entities, have an adequate opportunity to provide input. Agencies will evaluate the particular needs of the LEP persons they and theirrecipients serve and the burdens of compliance on the agency and its recipients. This input from stakeholders will assist the agencies in developing an approach to ensuring meaningful access by LEP persons that is practical and effective, fiscally responsible, responsive to the particular circumstances of each agency, and can be readily implemented.

Sec. 5. Judicial Review.

This order is intended only to improve the internal management of the executive branch and does not create any right or benefit, substantive or procedural, enforceable at law or equity by a party against the United States, its agencies, its officers or employees, or any person.



August 11, 2000.

Other Information 

Department of Health and Human Services Compliance with Executive Order 13166.

Additional compliance information and guidance may be found at www.lep.gov.

Medical Interpreter Standards

Voluntary Guidelines and Standards for Cultural and Linguistic Competence

CLAS guidelines are activities recommended by OMH for adoption as mandates by federal and state national accrediting agencies (Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13).

CLAS recommendations are suggested by OMH for voluntary adoption by health care organizations (Standard 14).

Standard 1

Health care organizations should ensure that patients/consumers receive from all staff members effective, understandable and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

Standard 2

Health care organizations should implement strategies to recruit, retain and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.

Standard 3

Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

* * *

Standard 8

Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.

Standard 9

Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments and outcomes-based evaluations.

Standard 10

Health care organizations should ensure that data on the individual patient's/consumer's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated.

Standard 11

Health care organizations should maintain a current demographic, cultural and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

Standard 12

Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities.

Standard 13

Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.

Standard 14

Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information.

Medical Interpreter Standards

The National Council on Interpreting in Health Care (NCIHC) develops standards for medical interpreters. For the full set of standards or to learn more about medical interpretation, consult the NCIHC website at www.ncihc.org . There are 32 standards.

Olmstead v. L.C. 527 U.S. 581 (1999); 138 F.3d 893

This landmark ruling by the U.S. Supreme Court in 1999 held that the unnecessary segregation of individuals with disabilities in institutions may constitute discrimination based on disability. The court ruled that the Americans with Disabilities Act may require states to provide community-based services rather than institutional placements for individuals with disabilities. For radiologic technologists, state efforts to de-institutionalize will mean an increased number of patients with other disabilities.

New Jersey

In 2005, the New Jersey legislature passed, and the governor signed into law, requirements that physicians in New Jersey undergo cultural competency training. While this pertains to physicians, it may only be a matter of time, once additional educational materials are developed, until it gradually become a requirement for all individuals in the health care professions.


Other Information and Resources

Office of Minority Health
CLAS Standards, information on health disparities, health resources for cultural and linguistic competency, useful links.

information and resources on government programs for individuals with limited English proficiency. Agency plans and resources are available through this website as well. Operated by the Interagency Working Group on Limited English Proficiency. The group was created at the request of Assistant Attorney General for Civil Rights. The Working Group includes members representing more than 35 federal agencies. The website is maintained by the U.S. Department of Justice.

"I Speak" Language Identification Flashcard (PDF) 

From the Department of Commerce, Bureau of the Census, the "I Speak" language identification flashcard is written in 38 languages and can be used to identify the language spoken by an individual accessing services provided by federally assisted programs or activities.

Department of Education Office of Civil Rights
Information on filing a civil rights complaint, published in several languages.

Official U.S. Government site in Spanish.

CDC en Español
Centros para el Control y la Prevención de Enfermedades: an internet gateway with information in Spanish on preventive health and safety.

CLAS-talk Listserv
Exchange ideas, find answers and learn what others are doing in the health care field pertaining to cultural and linguistic competence.

Health Disparities Tool Kit
information on collection of data. Data collection is a major part of determining health disparities by race and ethnicity. This tool kit can help.

For practice issues, email AskTheCouncil@asrt.org.