Assessing Cultural Competency from the Patient's Perspective: The CAHPS Cultural Competency Survey

Background: The objective of this study is to describe the development and testing of the Consumer Assessments of Healthcare Providers and Systems (CAHPS) Cultural Competency (CC) Survey, an instrument that addresses cultural competency domains that are not adequately addressed in the current version of CAHPS. Methods: 1) Five domains of culturally competent care from the patient's perspective were identified: a) Patient-provider communication; b) Respect for patient preferences/ shared decision-making; c) Experiences leading to trust; d) Experiences of discrimination; and e) Linguistic competency. 2) Based on an extensive literature review, a survey instrument was developed to capture the identified domains. 3) Survey items were translated to Spanish using a committee approach of certified translators and content experts. 4) Eighteen semi-structured cognitive interviews (9 in Spanish and 9 in English), with scripted probes, were conducted to assess patients' understanding of draft items. Findings were used to revise and refine items. 5) A field test, using mail and phone survey modes, was conducted with a random stratified sample (based on race/ethnicity and language) of enrollees from two Medicaid managed care plans (New York and California) in 2008. There were 991 surveys completed. 6) Psychometric analyses were conducted to examine the internal consistency and construct validity of the scales. 7) Regression analyses were conducted to assess convergent validity by regressing the CAHPS CC composites on an overall doctor rating (0-10), after controlling for gender, age, education, and perceived health status. Findings: Exploratory factor analysis (eigenvalues > 1) and confirmatory factor analysis (CFI= 0.91; TLI= 0.99; RMSEA= 0.04) provided support for an eight-factor structure: Doctor Communication-Positive Behaviors; Doctor Communication-Negative Behaviors; Doctor Communication-Preventive Care; Doctor Communication-Alternative Medicine; Shared Decision Making; Equitable Treatment; Trust; and Access to Interpreter Services. Item to total composite correlations were higher than 0.40 for all items. Internal consistency estimates of the eight composites ranged from 0.58 (Alternative Medicine) to 0.92 (Positive Behaviors), and exceeded 0.70 for five of the eight composites. All composites were positively and significantly associated with overall doctor rating. Conclusions: The CAHPS CC item set demonstrates adequate measurement properties, and deals with aspects of care that are important to patients' ratings of care. Among the strategies that have been advocated for reducing racial/ethnic differences in patient experiences with care is the provision of “culturally competent” medical care. The CAHPS CC item set can be used to measure culturally competent care from the patient's perspective and for quality improvement purposes.