Section Seven

Module 25: Continual Quality Improvement

  • How do organizations improve?

  • After working with the material in this module, readers will be able to

    • describe the benefits of continual quality improvement approaches that focus on the influence of enterprise- or system-level features

    • identify the features of a workgroup or professional system that represent the six stages of Cross et al.’s (1989) continuum of cultural proficiency

    • use Cross et al.’s (1989) five characteristics of a culturally competent service agency to analyze the characteristics of speech-language pathology groups or organizations

    • explain the distinction between cultural competence in a given situation and cultural proficiency’s emphasis on continually improving the larger situation for everyone, as defined by Cross et al. (1989)

Module 25 allows us to explore two sets of important interactions, using a classic model of cultural proficiency for organizations presented by Cross et al. (1989). As Cross et al. emphasize, our workplaces, facilities, and other systems influence our work as individuals while, at the same time, we as individuals influence our larger workplaces, facilities, networks, and other systems.

Continual Quality Improvement Systems

Have you ever been assigned to complete a task at work but not given the resources you needed?

You are assigned to complete a particular assessment instrument with a client, but there are no test booklets in the cabinet.

You are assigned to complete a new assessment instrument with a client, but you are not given any training about the new test or given adequate time to read through the new test before you administer it.

You are assigned to design and complete all necessary assessments with a new client whose home language and religion differ from yours, but you are not provided with any information about that language, that religion, or the specifics of arranging for cross-linguistic and cross-cultural assessments in your workplace.

What would happen in these situations? You would probably do okay, somehow, because you are a creative individual with excellent basic clinical skills.

But might you also waste time looking for test booklets, settle for giving the first client a different test instead, make a minor mistake in administering the new test, or stumble through some unnecessarily awkward moments with the third client that make both of you feel bad and that reduce the overall quality of the care that client receives?

Yes, you would, and in many ways those inefficiencies and errors would not be your responsibility. Successful workers are not successful in isolation. Successful workers function within thoughtfully designed and managed organizations that provide them with the materials and other supports that they need.

Effective workplaces are aware of these issues.

If you have ever had the pleasure of working in a well-organized and well-managed group, part of what you liked was probably that you were provided with all the necessary materials, training, information, policies, and procedures that you needed to feel good about your work. You probably also felt that you, your colleagues, your managers, and any higher levels of administration all shared the same basic assumptions about what needed to be done, how, why, by whom, and when. When all such elements are in place, the organization’s work tends to be done well, relatively easily, and by satisfied employees.

When any necessary tangible or intangible elements are missing, however, or when the pressures put on employees (or equipment) are at odds with the stated mission of the organization as a whole, the desired work might not be done well, might be much more difficult than necessary, might not be completed at all — or might lead to physical breakdowns of the equipment, imperfect physical products, or more grumbling, gossiping, and down-time than actual working among the employees.

Most business, manufacturing, healthcare, and education organizations attempt to address the need for these complete “enterprise-level” supports and resources using processes known variously as continual or continuous quality management or improvement. With respect to human workers, these terms refer to systems that seek to support current work, and improve future work, by focusing on the larger enterprise-level context of tangible and intangible supports provided (or not provided) to workers, and by attempting to understand the influence of the enterprise-level context on individuals’ decisions and actions.

The remainder of this module uses Cross, Bazron, Dennis, and Isaacs’s (1989) classic model of the enterprise-level infrastructure that is necessary for clinical service organizations or agencies that seek to provide culturally and individually appropriate care. Using Cross et al.’s model as our base, we can consider two questions. both of which are related to the resources that employees receive from organizations and related to the overall quality of services that individuals and organizations can provide.

How do enterprise-level or organization-level variables influence the cultural and identity-related aspects of our work as individual speech-language pathologists?

How can we as individuals improve the enterprise-level systems that, in turn, shape the cultural and identity-related appropriateness of our work?

Your Turn

You might be familiar with the meetings known as morbidity and mortality (“M&M”) discussions, which are a common part of quality improvement systems in medical settings. Productive M&M meetings seek less to punish a practitioner’s error and seek more to determine whether the error was predictable from contextual or infrastructural elements that should be changed (see, for example, the website of the Accreditation Council for Graduate Medical Education). The Joint Commission (2018) emphasizes that encouraging or even praising reports of “close calls” can actually serve as an effective system for preventing future errors. Have you ever been part of a useful M&M-type discussion? If not, can you imagine how such conversations might help in your workplace?

In our own profession, our Council on Academic Accreditation requires that all university training programs engage in “regular and ongoing” assessments to “evaluate the quality of the program,” “to facilitate continuous quality improvement” (CAA, 2017/2023, Standard 5.3, p. 28), and then to evaluate the improvements themselves (Standard 5.4). Healthcare organizations and schools are similarly required to engage in ongoing assessment and change, including ongoing assessment and change focused specifically on their cultural and identity-related work (remember from Module 4 that the CLAS Standards’ third theme requires healthcare organizations to engage in continuous assessment, improvement, and accountability processes focused specifically on culture and identity). Have you ever been part of this type of program-wide assessment? How effective were the conversations, and why?

Cross et al.’s (1989) Models for Culturally Appropriate Agencies and Systems

Cross, Bazron, Dennis, and Isaacs’s (1989) comprehensive monograph addressed cultural competence for agencies and organizations that provide mental health services to children with severe emotional disturbances from what they described as “four sociocultural groups of color: African Americans, Asian Americans, Hispanic Americans, and Native Americans” (p. iii).

As all continual quality improvement systems emphasize, Cross et al. addressed culturally appropriate work as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations” (Cross et al., 1989, p. 13).

As part of their effort to describe the required “behaviors, attitudes, and policies,” Cross et al. presented and discussed several pieces:

  • a 6-stage continuum of cultural competence or proficiency (their Chapter II)

  • five essential elements of cultural competence that must exist at every level of an agency or organization if it is to provide culturally competent care or engage in culturally proficient work (their Chapter III)

  • examples of how cultural competence must be developed at the levels of policy and administration before it can be expected at the practitioner level (their Chapter IV)

  • and suggestions for strategic planning for institutional change that focused on the agency or organization as a whole, including resource development and leadership development (their Chapter VI).

Cross et al.’s entire original monograph is easily available online and well worth reading. We will focus here on their 6-stage continuum of cultural competence or proficiency and then on their five essential elements that must exist at the organizational or enterprise level if the members of that group are to achieve culturally competent or proficient work.

Cross et al.’s (1989) Six-Stage Continuum of Cultural Proficiency

Box 25.1 summarizes the six stages of Cross et al.’s (1989) continuum of cultural competence or proficiency, updated and expanded here to include a wide range of cultural and individual identities. Notice that Cross et al. referred to the stages of this continuum as reflecting possible ways that any human services organization as a whole can respond to cultural differences, from actively attempting to destroy another culture, as the negative extreme, to actively attempting to work on behalf of each client and all cultures, as the positive extreme.

Read Box 25.1 carefully, and try to keep several levels of any agency, facility, building, organization, district, or unit in mind as you read. How might the leadership provided from a director’s office result in facility-wide actions that reflect each stage? How might such enterprise-level elements as promotion policies, clinic scheduling policies, or other large elements result in activities that reflect each stage? Each stage of the continuum could also describe the actions of one person, and you might recognize your own efforts at one or more of these stages, but Cross et al.’s emphasis was not on any practitioner alone; the point here is that we are all influenced by the systems within which we are expected to work.

Box 25.1. Key Features for Each Stage of Cross et al.’s (1989, Chapter II) Six-Stage Continuum of Possible Ways that Organizations Might Respond to Cultural Differences, Expanded Here to Address Cultures, Backgrounds, Identities, and Intersectionalities

 

  1. CULTURAL DESTRUCTIVENESS

Active attempts to destroy, harm, or reject the worth of any culture, group, or identity, including active atempts to reject the worth of any section from anywhere within any of Hofstede’s (2011) dimensions or Morgan’s (1996) continua, any intersectionality of these features, or the relevant individuals

 

2. CULTURAL INCAPACITY

Biased against a particular culture, group, or identity, or biased against any culture or people other than one’s own; no active attempts to harm, deny, or reject another group or identity but accepting of any inequities that do occur; unable because of this bias to work effectively with people from the relevant group or background or on their behalf

 

3. CULTURAL BLINDNESS

Focusing on, but not getting beyond, the notion that “we are all human”; advocacy for a “universal” approach that actually reflects one specific option and disproportionately benefits persons or groups with the authority to select the “universal”

 

4. CULTURAL PRE-COMPETENCE

Acting in a way intended to be “sensitive to” another group’s beliefs or the needs of people with a particular background, identity, or intersectionality but from a framework influenced by an out-group homogeneity bias; attempting to act differently to meet another group’s needs while continuing to see “them” as a simpler and homogeneous group and/or “our way” as better; actions performed to meet the needs of another group using an underlying assumption that such needs can be listed and checked off (e.g., tokenism in hiring); addressing cultural concerns through “heroes-and-holidays” recognitions rather than acknowledging the simpler daily elements and the more complex aspects of another group’s dynamic culture

 

5. CULTURAL COMPETENCE

Actions in each situation and in all situations flow from a true respect for the multiple equally valid options that other persons and groups are assumed to present; decisions and actions in every situation are modified appropriately to meet the needs and values of the persons or groups involved, based on the agency’s presumption that each person’s or group’s needs and values are valid and equal to any other person’s or group’s

 

6. CULTURAL PROFICIENCY

Culturally competent, plus also seeking to envisage and generate improvements to the entire system for groups we will never encounter

What were your reactions, as you read Box 25.1? If you couldn’t help but read as an individual, you might have identified with some aspects of cultural pre-competence (you’re trying!) and cultural competence (and sometimes you succeed!) in your work. If you were reading with systems in mind, however, you probably recognized many examples from throughout our profession at every level of Cross et al.’s continuum.

The description of cultural destructiveness, for example, might have reminded you of the Indian Schools, from Module 11, or our profession’s overall tendency to focus on “standard” spoken English, rather than allowing people to use their many dialects and languages. Schools, as systems, are still criticized by many scholars using the same words Cross et al. used more than 30 years ago: Many students are expected to “lose or deny their languages, literacies, cultures, and histories in order to achieve in schools” (Alim & Paris, 2017, p. 1). Teacher education programs, at another level of the system, continue to admit primarily White, middle-class women as students (Ladson-Billings, 2017), as do speech-language pathology master’s programs, thus potentially perpetuating systems that are designed to “get…working-class kids of color to speak/write/be more like middle-class White ones” (Alim & Paris, 2017, p. 3). Accent modification with adults has also been framed as a hegemonic system of organized cultural destructiveness (Yu, Nair, et al., 2022). Ongoing discussions about accepting neurodiverse or otherwise diverse speech, language, and behavior (as we addressed throughout Sections Two and Three) are similarly rooted in attempts to change traditions that can be framed as system-level cultural destructiveness aimed at people or groups who occupy a range of places on a range of continua.

Alternatively, you might think of these and similar examples as reflecting cultural incapacity, rather than cultural destructiveness. Cultural incapacity differs from cultural destructiveness in that cultural incapacity does not actively attempt to harm, deny, or reject any group or its individuals, and we can probably make a fairly good case that some of the problematic systems in speech-language pathology demonstrate incapacity, not destructiveness. (I also tend to think of this as a distinction without a difference; neither destructiveness or incapacity is our goal, and despite their distinctions they are both problematic. Let’s avoid both, rather than focusing too much effort on distinguishing between them.)

What about cultural blindness? My well-intended students are often surprised, at first, to find cultural blindness toward the negative end of Cross et al.’s (1989) continuum, precisely because their goal of treating everyone the same way reflects the “well-intended liberal philosophy” (Cross et al., 1989, p. 15; see also Kohnert, 2013, and our discussions in Module 15) that characterizes this level. But cultural blindness remains toward the negative or culturally destructive end of Cross et al.’s continuum for several important reasons.

Cultural blindness remains toward the negative or culturally destructive end of Cross et al.’s continuum because it shares with the first two stages a failure to seek, accept, value, and support the specific characteristics and identities that other people describe as their own and that matter to their lives.

Moreover, the assumption that “color or culture make no difference” because “all people are the same” often becomes, in practice, a system whose services are the ones understood and used by the dominant or majority groups in that geographic area (Cross et al., 1989, p. 15). The stated logic is that everyone will benefit from universally good services because all people are people and because good services are good services; the resultant problem is that people who do not share an assumed definition of what “we all” do, or what “we all” are, or what “good” might mean in a certain situation, end up excluded or treated in ways that do not meet their needs. Remember that a true universal is several layers up, at the level of safety, health, or dignity; the specific ways that we each experience those universals depend on our backgrounds, cultures, experiences, and identities.

Cross et al.’s (1989) next stage, cultural pre-competence, attempts to solve some of the problems associated with destructiveness, incapacity, bias, or blindness. Cultural pre-competence was so named because the “agency realizes its weaknesses in serving minorities and attempts to improve some aspect of their services to a specific population” (p. 16). At this stage, the organization has “begun the process of becoming culturally competent” (p. 17).

The continuing problems at this stage, however, include a relatively narrow focus on one “specific population.” Organizations characterized by cultural pre-competence also often reflect what we described as stereotypes, prejudices, and the out-group homogeneity bias, or the continued ranking and minimizing of a group that is still seen as a simple and homogeneous “other.” Cultural pre-competence, which might also be called cultural sensitivity or cultural awareness, might reflect some breadth, but this stage’s lack of depth continues to limit pre-competence to what have been called “heroes and holidays” recognitions (Lee, Menkart, & Okazawa-Rey, 2008). Institutionally, this stage is often characterized by tokenism in hiring, one-time or annual training programs that staffs endure but joke about, and single short-term projects.

Cultural pre-competence wants to help, in short, but it wants to help on its own terms. Cultural pre-competence might pride itself on being willing to learn about the views of another group, and might even be willing to act in a way intended to be consistent with the beliefs of that other group, but it still sees the other group as a “them”: a simple, homogeneous, and less informed group that should be happy with whatever assistance the pre-competent agency has deigned to provide.

One of my best examples of enterprise-level pre-competence is that for many years my college held a “multicultural resources fair” and invited a salsa band to play. The gesture began as a well-intended attempt to recognize a culture that is present but non-dominant in our geographic area, which was certainly a better impulse than cultural destructiveness, incapacity, or blindness. The problem was that the impulse went no further; everything about all the many different Spanish-speaking cultures on three continents was reduced to the stereotyped entertainment value of a salsa band.

The fair was also held literally on our own front lawn, instead of where anyone who needed the resources was more likely to be.

If cultural pre-competence is trying to help in our own way, or at least is trying to recognize part of what another group is and needs, then cultural competence is succeeding in helping in the way someone else needs, or succeeding in valuing as much about them as we possibly can. As we have emphasized throughout this website, such a shift requires that our systems and our actions stem from a genuine understanding of, and respect for, the full range of all equally valid positions along, and interactions of, all relevant dimensions and continua.

Systems acting with cultural competence provide all clients with the care they need and want in a way that not only expects the clients to have their own cultural needs and values but also conveys and responds to the importance of those cultural needs and values – whether the person or agency providing the care shares the client’s background or not.

Culturally competent actions, in other words, are shaped by two defining enterprise-level elements:

  • a system-level understanding that all groups and all individuals have their own equally important needs and values;

  • and a system-level ability to modify the care provided to every client, and to modify the professional interactions that occur within the agency and as interprofessional connections, such that the giver’s actions respect the recipient’s values (not the giver’s) and meet the recipient’s needs (not the giver’s).

So are we finished?

Cultural competence, system-level understandings, system-level abilities to modify individual actions with individual clients, respecting and responding to the clients’ needs.

Sounds good, doesn’t it?

Yes, it does, but the beauty and the importance of Cross et al.’s model is that it does not stop here. Cultural competence in current interactions is important, but cultural competence is limited to current interactions. There’s a final stage, which Cross et al. referred to as “cultural proficiency,” and it is an absolutely critical stage.

Cross et al.’s (1989) final stage of cultural proficiency combines cultural competence with additional efforts to envisage and generate ongoing improvements in multiple dynamic systems.

Culturally proficient institutions or agencies, in Cross et al.’s terms, move beyond recognizing each client’s needs and reacting in appropriate ways, and move beyond valuing and meeting the identified needs of their current or existing communities.

Instead, culturally proficient systems are proactive about truly holding culture and all cultures “in high esteem” (Cross et al., 1989, p. 17) and therefore are proactive about developing and distributing new knowledge and new practices in ways that value diversity, that value inclusion, that value and support all cultures, that value and improve how members of all cultures interact, and that are generating changes and improvements for people and times well beyond current clients or colleagues.

The distinction between cultural competence and cultural proficiency, as Cross et al. (1989) defined the two stages, has been somewhat lost in some later summaries of their model [e.g., the brief description provided by ASHA (n.d., Cultural Responsiveness) and based on Cross (2012)], but I believe it to be a crucial and defining feature of their monograph as a whole and of their overall message (and of Cross’s ensuing decades of work; see the Your Turn segment about him at the end of this module).

Cultural competence, in these terms, is important but static and limited; it addresses our current cross-cultural work in any existing situation with any current client or colleague.

Cultural proficiency, in contrast, includes working appropriately with current clients and colleagues as a minimal baseline and then also adds the crucial dynamism of continual quality improvement, including anticipating the needs of future people in future situations.

Your Turn

Box 25.1 might have implied that the six stages are equidistant, but I do not perceive Cross et al.’s (1989) continuum as an equal-appearing intervals scale. Try placing the six stages of the continuum along a line in a way that shows meaningful metaphorical distances between the consecutive pairs of stages. If cultural destructiveness is at the far left, and cultural proficiency is at the far right, then where exactly should cultural incapacity fall? Is the distance from cultural incapacity to cultural blindness more or less than the distance from cultural blindness to cultural pre-competence? Why?

Select any cultural or identity-related issue that is currently relevant for your facility, workplace, school, or other unit. Then think about what the enterprise-level or agency-level elements would look like for that issue, and what the influence of those elements on individual practitioners would be, if your group were approaching it at each of Cross et al.’s six stages. That is: Start by imagining that your entire organization, as a whole, was approaching this issue using culturally destructive policies or procedures. What would your organization’s policies and procedures for this issue be, if your group were approaching the issue in a culturally destructive way? Then move up a stage: What if your directors and your policies were approaching the issue with cultural incapacity? Continue until you have thought about how this issue would be addressed, at the organizational or enterprise level, at each of the six stages. How would the enterprise-level elements you are imagining influence the decisions made or the work done by individual practitioners, even if the individual practitioners might be seeking to do culturally appropriate work?

Select any other issue that is currently relevant for your facility, workplace, school, or other unit and that does not appear on the surface to be cultural or identity-related. Has your group been engaged recently in dealing with the leaky roof in the old building, buying new whiteboards for the scheduling office, or arranging a retirement party? Think, again, about what the enterprise-level or organization-level elements would look like for that issue if your group were approaching it at each of Cross et al.’s six stages, even though this issue is ostensibly not a cultural one. Start with cultural destructiveness: If the issue was a leaky roof, and your systems were functioning at a level of cultural destructiveness, your managers might actively decide to assign certain workers and certain clients to use the wet moldy rooms while assigning other workers or clients to the safe spaces in the new building. What do you notice as you think through any ostensibly non-cultural issue using Cross et al.’s systems-level continuum?

As we will address throughout this module, no agency is ever functioning solely at one level of Cross et al.’s continuum. What is usually happening, instead, is that parts of their work reflect one stage, while other parts reflect another stage, while still other parts reflect yet another stage. Think about the example situations you have been evaluating for your facility, workplace, school, or other unit. Which aspects of what is actually currently happening in your world reflect which stages of Cross et al.’s continuum?

Cross et al.’s (1989) Five Essential Elements of Working Effectively with Culture that Must Exist at Every Level of an Agency or System

In addition to their six-stage continuum of possible responses to cultural differences, Cross et al. (1989) also provided a thoughtful list of what they referred to as five essential elements of any organization that seeks to provide culturally competent services or seeks to work toward cultural proficiency. In many ways, the ideas here overlap with the descriptions of culturally competent work and culturally proficient work, but there are also some important additional elements to think about.

As you read Box 25.2, continue to think in terms of the many levels that create an agency, enterprise, facility, district, or organization – or our entire profession.

Box 25.2. Cross et al.’s (1989, Chapter III) Five Elements of a Culturally Competent Human Services Agency, System, Organization, or Profession, Expanded to Address Cultures, Backgrounds, Identities, and Intersectionalities

 

1. VALUES CLIENTS’ DIVERSITY

the system accepts, respects, and expects that its clients will bring different assumptions and will make different choices based on their cultures, backgrounds, and identities; the system is prepared to work equally effectively with clients who have different needs or have made different choices

2. ASSESSES ITSELF AS A CULTURE

the system recognizes and is aware of its own assumptions as a system; the system as a whole understands that interactions will be cross-cultural not only because of personal differences among workers, among clients, and between workers and clients but also because of the differences between the system’s culture as a system and the clients’ cultures, backgrounds, and identities

3. PREPARES FOR THE DYNAMICS OF DIFFERENCE

the system minimizes the occurrence of cross-cultural misjudgments or misinterpretations by recognizing that cross-cultural interactions necessarily include the potential for misjudgments or misinterpretations; the system’s policies and procedures position it and its levels to respond to cross-cultural differences as opportunities for ongoing “creative energy” (Cross et al., 1989, p. 20) rather than as problems

4. INCORPORATES KNOWLEDGE AND LEARNING ABOUT CULTURES

the system provides information to its workers about culture, about cultures, and about working with multiple cultures; the system supports its workers by providing them with information and resources for continuing to gain relevant and dynamic knowledge about cultures generally and about the system’s current and future clients

5. ADAPTS TO CLIENTS’ DIVERSE NEEDS

the system develops and uses alternative methods for its work that are actively intended to meet the needs of clients from different cultures, backgrounds, and identities; the system seeks actively to adapt its goals and methods so as to meet current and future clients’ different and dynamic needs

How many levels of our profession could you keep in mind at one time, as you read Box 25.2?

If you were thinking of ASHA as a whole, you might have been aware that ASHA as a large agency is attempting to demonstrate all five of these elements for our profession as a whole through such profession-wide elements as the Council on Academic Accreditation’s (CAA) current requirements for educational program accreditation (which have recently been expanded to require specific cultural elements at the program level; CAA, 2023). Other recent changes to certification requirements and continuing education requirements have emerged from the profession’s evaluation of itself (Cross et al.’s second point, in Box 25.2) and reflect some attempts from the highest levels of our profession to provide leadership and policies that value clients’ diversity, prepare all members of the profession for the dynamics of difference, engage all speech-language pathologists in ongoing learning about culture, and position our profession to adapt to clients’ diverse needs. The ASHA Leader also currently routinely publishes a wide range of pieces about culture, cultures, and identities in speech-language pathology.

At other levels, does your hospital system, school district, or university system reflect one or more of these five traits? Does your building, unit, college, or private practice group? Does your rehabilitation services team, your special education team, or your Human Resources Office?

If so, you might find that you feel more supported in your efforts to provide culturally competent services and to aim for cultural proficiency in your work; the elements in Box 25.2 are essentially supportive resources that an organization or agency can provide or not provide to its workers.

If your organization does not currently provide you with the information, materials, policies, procedures, and other supports listed in Box 25.2, however, your attempts to provide client-centered, culturally and individually appropriate care might feel very much as if you were being asked to give a standardized test by an employer who has not provided you with a packet of test forms. Many choices and actions are individual, but the actions that individuals can take in any organizational or enterprise-level context are influenced, if not controlled, by the characteristics of the organization, agency, or system itself.

Your Turn

Create a Venn diagram or another visual representation of all eleven institution-level elements addressed by Cross et al. (1989) (combining Boxes 25.1 and 25.2). How many dimensions do you need, to show how these complex agency-level features interact?

Several previous Your Turn segments have addressed the following three definitions, which are provided in ASHA’s (2020) Standards and Implementation Procedures for persons seeking individual certification in speech-language pathology:

“Cultural competence: The knowledge and skill needed to address language and culture; this knowledge and skill evolves over time and spans lifelong learning.

“Cultural humility: A lifelong commitment to engaging in self-evaluation and self-critique and to remedying the power imbalance implicit to clinical interactions.

“Culturally responsive practice: Responding to and serving individuals within the context of their cultural background—and the ability to learn from and relate respectfully with people of other cultures.”

Revisit these definitions now, in the context provided by Cross et al.’s (1989) six-stage continuum and five elements of a culturally appropriate organization. Which aspects of Cross et al.’s total of 11 features are apparent in ASHA’s definitions? To my reading, ASHA’s definitions seem to focus more on Cross et al’.s cultural competence stage and less on the key, forward-facing aspects of cultural proficiency. Is that how you read ASHA’s definitions? Why or why not?

The Standards for Accreditation of Graduate Education Programs in Audiology and Speech-Language Pathology (Council on Academic Accreditation, 2023) drew on Cross et al. (1989) for their definition of cultural competence (which was one of the many reasons I chose to organize this entire module around Cross et al.’s 1989 original paper):

“Cultural and linguistic competence is an asset [sic] of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations…. ‘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.” (CAA, 2023, p. 37; emphases added)

Why do you think the CAA focused on Cross et al.’s stage of cultural competence, rather than their stage of cultural proficiency?

Think about how educational program accreditation requirements shape educational programs which shape individual new practitioners (who shape our profession and ultimately shape the next generation of educational program accreditation requirements). Should the requirements for individual licensure or certification emphasize that individual practitioners need to understand the influence of agency-, group-, or organization-level variables (such as Cross et al.’s five elements, in Box 25.2) on the cultural appropriateness of the work they will be able to do? If such system-level content is viewed as too much for individual graduate students or new practitioners to be able to manage, how does that view or decision itself shape the field? When should individuals be expected to become aware of the dynamic two-way influences between themselves and their groups?

Working with Cross et al.’s (1989) Agency-Level Elements of Cultural Proficiency: Decorating in December

Happy December! Let’s try an extended example that allows us to use Cross et al.’s models.

Think about a rehabilitation unit or agency that includes physical therapists, occupational therapists, and speech-language pathologists.

They would like to decorate their facility’s physical therapy gym in December, with a goal of making the space happy and welcoming for everyone at a dark time of year.

Someone suggests a Christmas tree, but the group recognizes that overtly religious symbols could be inappropriate. They settle on using some red and green decorations, some snowflakes, and some cute little reindeer. One of the occupational therapists (who is not Jewish) suggests adding some large boxes wrapped in blue and silver, and the group agrees.

(How are they doing so far? Do you see any elements of Cross et al.’s (1989) continuum yet?)

A couple days after the group had decorated the gym, one of the speech-language pathologists overheard a family talking to each other quietly on the way out, after their elderly father’s appointments. One of the younger members of the family was saying that she wanted to say something to the director about the “discriminatory” decorations; another family member suggested that they could try to find a different practice for Dad’s therapies. Their father told them it was all okay, that he could ignore the decorations, that he likes the individual therapists, and that they should be used to such things by now.

The speech-language pathologist recognized what the family was saying and what they meant. She balanced this conversation in her mind with the several compliments she had heard from other families about the decorations, and she decided not to tell anyone what she had overheard. The family did return for their appointments the next week, and Dad seems to be progressing well in his rehabilitation.

(Hmm. Now what’s happening?)

Use Boxes 25.1 and 25.2 to think about every detail of this story. What happened, what could have happened instead, what should have happened, and who should do what now? Remember that most organizations are functioning at several levels of Cross’s continuum simultaneously, not at a single identifiable level.

When you’re ready, continue to the debriefing below – but wrestle with it all yourself for a bit before you move on!

Debriefing our Decorations

December decorations in a shared workspace might not be the most serious example of these issues you will ever come across, but remember that discrimination need not be large to be problematic. Let’s start at the bottom of Cross et al.’s (1989) continuum and talk it through.

Red and green decorations in December, with snowflakes and reindeer, is a Christmas display, and a good case could be made that these decorations represent cultural destructiveness. The therapists in our story probably were not actively seeking to impose on anyone the harm of making them feel excluded or unwelcome or uncomfortable in shared spaces, but one reasonable way to interpret their decision-making is to say that they were denying the existence in a shared space of clients and coworkers who do not celebrate Christmas. (The grown children in this story felt this exclusion explicitly, described the decorations as “discriminatory,” and wanted to find another clinic.)

Did you interpret the staff’s actions as closer to cultural incapacity, though, rather than as genuine destructiveness? They did at least have the initial discussion that recognized the inappropriateness of a Christmas tree (some evidence that they value diversity at least to some extent, can assess their own actions at least somewhat, and are adapting their original plans at least a little bit). The logic of Christmas decorations in a professional workspace often fits Cross et al.’s definition of cultural incapacity quite well: The people in the cultural or religious majority decorate a shared space in a way that they recognize might make some people feel somewhat excluded, but they decide that the inequity to “other” people of “merely” feeling left out is “minor.” Even given the explicit feedback from the family discussing the decorations in our story, the speech-language pathologist who overheard them decided that discriminating against them on the basis of religion, in that they are having a different emotional experience in this space than people from a Christian background are having, was an acceptable inequity. In Cross et al.’s terms, she was incapable of learning from, or adapting her or her group’s behavior based on, the explicit information about the dynamics of difference that this family was clearly providing.

(“Rights” arguments often come in about here. A group might have the “right” to put things in their gym even if it causes what they judge to be a “minor” inequity to other people, but our role and responsibility as professionals is to be thinking about how to serve all clients, not about how to demonstrate our own rights. Arguing that “most” people in a community celebrate Christmas, and suggesting that just seeing some cute reindeer in the gym really shouldn’t be that much of a problem for people who don’t celebrate Christmas, are both cultural incapacity arguments, too.)

What about the cultural blindness stage? Did you notice that the staff agreed that a Christmas tree would be inappropriate but then convinced themselves that red and green decorations in December are universal and that everyone enjoys cute little reindeer? Again, they were attempting to assess themselves, but they were not genuinely valuing all cultures or adapting their work in a new way so as to meet all clients’ needs. 

You probably also noticed the cultural pre-competence from the occupational therapist who wanted to add blue and silver packages. Pre-competence might masquerade as assessing our work and making adaptations to value culture, but pre-competence oversimplifies other groups, depends on stereotypes, and provides only token recognition. In this story, cultural pre-competence said, “Some people celebrate Channukah in December! I will act on this realization by putting a gift wrapped in blue and silver at the edge of the display. Now I am including them, and now I can check them off my list” – even though, of course, blue packages in December are a small part of what it means to be Jewish and represent a terrible stereotype that mocks the many complexities of Jewish people, families, and traditions. Notice also that the decision to add Jewish symbols to a Christmas display implicitly assumes that the world can be divided into people who are Christian and flexible and inclusive and kind and understanding, on the one hand, and people who are Jewish, who like blue gifts, on the other, and no one else. (Remember that we tend to recognize the complexities within our own cultures, but we tend to hugely oversimplify everyone else – the outgroup homogeneity bias.)

Cultural competence in this story would have required actions that reflected genuine respect for all coworkers and all clients.

As we have said, a culturally competent workgroup would value diversity, assess itself, prepare for and benefit from the dynamics of difference, engage in routine continual learning, and adapt its actions so as to recognize, respect, and respond to all clients’ cultures, backgrounds, identities, and needs. At the higher levels of their agency, organization, or enterprise, as well, the staff members in our story might have benefited from policies, practices, budgets, and training that would have helped them as they made their decisions. As we have been emphasizing throughout this module, assigning individual workers to complete any task, including “decorate for December,” must include providing them with the tangible and intangible supports that they need to do the job well.

What could this example have looked like, instead? Was cultural competence or cultural proficiency possible?

Of course it was — and still is!

The group needs to step back, first, and ask why they are decorating the gym in December. They also need to reflect on and discuss their assumptions, their implicit views, and what they believe to be appropriate for whom.

They might then come to the recognition, as a group, that their goal was to make being in the physical therapy gym in the wintertime a better experience for everyone – a positive and worthwhile goal. The problem was not their original impulse, if this was their original impulse; the problem was that this goal will never be achieved by decorating with oversimplified versions of symbols from two religions or pretending that a dominant religion should be viewed as a shared universal. How, then, might the group of therapists have gone about their decorating process?

They could have asked their clients and families what they would have liked to see when they came into the gym in December. Such an effort could reflect the group’s attempt to value other views, assess their own actions, and adapt their actions to meet the needs of their current clients, but this approach also runs several risks. Most problematically, such surveys may result in little more than another layer of cultural incapacity or cultural blindness, now with the artificial safety of pretending to be responding to the community’s needs. Regardless of the feedback on the surveys, a majority vote in favor of a nativity scene does not make it okay to put a nativity scene in your lobby.

The answer probably lies, instead, in their original and wonderful goal: to make everyone’s experience in the gym a little better.

What might that look like?

  • Do they need better space-heaters in the entryway during the winter?

  • Do they need more umbrella stands and several solid coat-racks for a couple months?

  • Perhaps a new awning out front that covers the wheelchair ramp?

  • New magazines in the waiting room or to be used for aphasia therapy?

  • Fresh new straps, pads, and gait belts in the gym, in many different colors?

I can almost hear your objections from here, whether you are an entry-level therapist or an experienced manager: There’s no budget for space heaters! We don’t have any authority about the awnings, that’s Physical Plant’s job! And we don’t have time for any of this, our caseloads are too big!

These objections reflect everything about the importance of Cross et al.’s point that cultural competence and cultural proficiency must exist at the agency level (Box 25.2). An agency that values client comfort in December needs a budget for space heaters. An agency that values clients’ experiences year-round needs systems for communications among departments, including maintenance, physical plant, billing, and all others. And an agency that wants therapists to have time for culturally proficient work needs to assign therapists time for culturally proficient work. We cannot, you are absolutely correct, expect individual employees to do things that employers’ structures prevent.

And also, maybe, to return to our simple decorations questions, the answer might be bright yellow suns to cheer people up in the dark winter, if the goal was merely to decorate in a way that might cheer people up in the wintertime.

What was the therapists’ goal, at the beginning of the story?

Was their goal to use decorations to cheer up all clients and all families in the wintertime and to make everyone’s experience a little better?

It might have been, and if so they will find a good solution.

The problem, sometimes, is that some work groups are empowered by some agencies to be thinking in other ways. It might be acceptable, in this facility or in this school, to communicate through our decorations that we like Christmas decorations, that Christian backgrounds are more “typical” or more “normal,” that Christian backgrounds are preferred or privileged in this workplace, that clients who are Christian belong here more than other clients do, or that Christian clients are more deserving of seeing their culture’s colors and symbols reflected in the decorations at the physical therapy gym than other clients are.

As we said, December decorations in a shared workspace might not be the most serious example of discrimination or of cultural competence issues that we could have addressed, but discrimination need not be large to be problematic. Sometimes, as with the pedestrian safety data we addressed in Module 9, discrimination creates immediate danger. Sometimes, as our discussions of raciolinguistic biases (Module 8) and social determinants of health (Module 10) addressed, the problems are less immediately fatal, but a slow death by a thousand small cuts is a death nonetheless.

As we continue to think about not only our own individual actions but also our agencies’ and organizations’ policies, procedures, assumptions, and actions, Cross et al.’s (1989) continuum, and their five necessary elements of a culturally appropriate organization, provide some complex and important ways we can be thinking about our work. More importantly, Cross et al.’s models provide us with an important awareness that the answers will probably include asking our managers for the support that we need, or acting in appropriate ways if we are the managers, to allow our agencies, facilities, and work groups to be continually seeking enterprise-level improvements.

Cultural proficiency, in Cross et al.’s terms, includes our on-going efforts toward continual improvements for ourselves and for our workplaces. It’s a lot to debrief, and it’s an important set of thoughts.

Your Turn

What was your reaction to the December decorations example? How does your reaction reflect who, what, when, and where you are from, in, with, and for (from our Module 2)?

Terry L. Cross, the lead author of the original monograph upon which this module was based, served as the founding executive director of the National Indian Child Welfare Association (NICWA) in the 1980s. As of early 2025, he was still serving as that organization’s Senior Advisor. Depending on where you live or where your journeys have taken you, you might be familiar with the NICWA’s work directly or through one of its partner organizations. If you are not familiar with the agency, try reading parts of their website; it’s an outstanding model for professionals in a wide range of disciplines working with a wide range of people and cultures.

Highlight Questions for Module 25

Explain the distinction between an individual worker’s efforts to do good work and the supports for good work that are provided (or not provided) to individual workers by their system, facility, agency, or other larger enterprise. Describe the benefits of continual quality improvement approaches that focus on the influence of system-level or enterprise-level features (versus merely expecting individuals to do good work). Can you name some examples from your past or present jobs?

Name and describe the six stages of Cross et al.’s (1989) continuum of cultural proficiency (Box 25.1). What individual knowlege, skills, or dispositions would individual workers have, if they are working at each stage? What facility-wide or enterprise-level characteristics must be in place, if any part of the organization’s work reflects that stage?

Think about any issue, goal, or topic that is currently relevant for your facility, workplace, school, or other unit, whether you think of that topic as a “cultural” topic or not. Analyze the topic using Cross et al.’s (1989) six-stage continuum (Box 25.1). Which aspects of what is currently happening reflect which stage? (Remember that most institutions are functioning in ways that reflect multiple levels simultaneously, not sitting “at” any one stage.) Would you like to see your workplace change anything about how it is addressing this topic?

Review Cross et al.’s (1989) five characteristics of a culturally competent service agency (Box 25.2). Use those characteristics to analyze your current agency, facility, or system, or to analyze any organization you have previously worked for. (Try thinking about the fast-food restaurant you worked at, the retail job you had in high school, or your boring summer job from college. Were those organizations designed to provide culturally competent services to all clients or customers?)

Explain the distinction between cultural competence in a given situation and cultural proficiency’s emphasis on continually improving the larger situation for everyone, as defined by Cross et al. (1989).