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National Healthcare Quality Report, 2013

Chapter 6. Patient Centeredness

The Institute of Medicine identifies patient centeredness as a core component of quality health care (IOM, 2001a). Patient centeredness is defined as:

[H]ealth care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care (IOM, 2001b).

Patient centeredness "encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient" (IOM, 2001a). In addition, translation and interpretation services facilitate communication between the provider and the patient and are often a legal requirement.i The patient-centered approach includes viewing the patient as a unique person, rather than focusing strictly on the illness, building a therapeutic alliance based on the patient's and the provider's perspectives.

Patient-centered care is supported by good provider-patient communication so that patients' needs and wants are understood and addressed and patients understand and participate in their own care (IOM, 2001b). This approach to care has been shown to improve patients' health and health care (DiMatteo, 1998; Stewart, et al., 2000; Little, et al., 2001; Anderson, 2002; Beck, et al., 2002). Unfortunately, many barriers exist to good communication.

Providers also differ in communication proficiency, including varied listening skills and different views from their patients of symptoms and treatment effectiveness (Rhoades, et al., 2001). Additional factors influencing patient centeredness and provider-patient communication include:

  • Language barriers.
  • Racial and ethnic concordance between the patient and provider.
  • Effects of disabilities on patients' health care experiences.
  • Providers' cultural competency.

Efforts to remove these possible impediments to patient centeredness are underway within the Department of Health and Human Services (HHS). For example, the Office of Minority Health has developed a set of Cultural Competency Curriculum Modules that aim to equip providers with cultural and linguistic competencies to help promote patient-centered care (OMH, 2013).ii

These modules are based on the National Standards on Culturally and Linguistically Appropriate Services (CLAS). Enhanced CLAS standards now also include broader conceptualization of culture, audience, health, and recipients.iii The standards are directed at health care organizations and aim to improve patient centeredness of care for people with limited English proficiency (LEP).

Similarly, the HHS Office for Civil Rights' (OCR) Medical Education Initiative promotes a scenario-based curriculum on health disparities and cultural competency designed to educate student physicians, medical educators, and other health care providers on their civil rights obligations under Title VI of the Civil Rights Act of 1964. The curriculum, Stopping Discrimination Before It Starts: The Impact of Civil Rights Laws on Health Care Disparities, funded in part by the National Institutes of Health and the Stanford University School of Medicine, was presented to more than 300 student physicians and other health care providers in 2013.

The curriculum discusses, in part, the HHS OCR's Guidance to Federal Financial Assistance Recipients Regarding Title VI's Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. This guidance explains how recipients of Federal financial assistance must take reasonable steps to ensure individuals with LEP are provided a meaningful opportunity to participate in HHS-funded programs. Failure to do so may violate the prohibition under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq., against national origin discrimination (HHS, 2003).

In addition, the HHS OCR is responsible for the enforcement of Section 1557 of the Affordable Care Act, 42 U.S.C. 18116. This section provides that an individual shall not, on the grounds prohibited under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq. (race, color, national origin); Title IX of the Education Amendments of 1972, 20 U.S.C. 1681 et seq. (sex); the Age Discrimination Act of 1975, 42 U.S.C. 6101 et seq. (age); or Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794 (disability), be excluded from participation in, be denied the benefits of, or be subjected to discrimination under, any health program or activity, any part of which is receiving Federal financial assistance, or under any program or activity that is administered by an executive agency or any entity established under Title I of the Affordable Care Act or its amendments.

On February, 26, 2013, the Department published its 2013 Language Access Plan (2013 HHS LAP; HHS, 2013), ensuring access to HHS programs and activities for people with LEP. The covered programs and activities include, but are not limited to, Medicare, civil rights enforcement, and other HHS programs that provide benefits or services. The 2013 HHS LAP was developed by the HHS Language Access Steering Committee, which is led by the Director of the OCR on behalf of the Secretary.

In accordance with Executive Order 13166, Improving Access to Services for Persons With Limited English Proficiency (White House, 2000), the 2013 HHS LAP establishes the Department's policy and strategy for serving individuals with LEP and reaffirms the Department's commitment to language access principles. The 2013 HHS LAP serves as a blueprint for HHS staff and operating divisions charged with developing their own agency-specific language access plans. Additional information regarding language access requirements is available from the Department of Justice (DOJ, 2011).

The 2013 HHS LAP is organized into 10 cross-cutting elements:

  • Assessment—Needs and Capacity.
  • Oral Language Assistance Services.
  • Written Translations.
  • Policies and Procedures.
  • Notification of the Availability of Language Assistance at No Cost.
  • Staff Training.
  • Assessment—Access and Quality.
  • Stakeholder Consultation.
  • Digital Information.
  • Grant Assurance and Compliance.

Importance

Morbidity and Mortality

  • Patient-centered decisionmaking (when physicians take into account the needs and circumstances of a patient) for planning a patient's care has been shown to improve health care outcomes (Weiner, et al., 2013).
  • Patient-centered approaches to care have been shown to improve patients' health status. These approaches rely on building a provider-patient relationship, improving communication, fostering a positive atmosphere, and encouraging patients to actively participate in provider-patient interactions (Stewart, et al., 2000; Anderson, 2002).
  • A patient-centered approach has been shown to lessen patients' symptom burden (Little, et al., 2001).
  • Patient-centered care encourages patients to comply with treatment regimens (Beck, et al., 2002).
  • Patient-centered care can reduce the chance of misdiagnosis due to poor communication (DiMatteo, 1998).

Cost

  • Poor communication, lack of collaboration, and lack of support for self-care are associated with suffering and waste in health care (Øvretveit, 2012).
  • Patient centeredness has been shown to reduce underuse and overuse of medical care (Berry, et al., 2003).
  • Patient centeredness can reduce the strain on system resources and save money by reducing the number of diagnostic tests and referrals (Little, et al., 2001).
  • Although some studies have shown that being patient centered reduces medical costs and use of health service resources, others have shown that patient centeredness increases providers' costs, especially in the short run (Bechel, et al., 2000).

Measures

The National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR) track several measures of patients' experience of care. The reports also address the priority of ensuring that each person and family is engaged as partners in their care, found in the National Strategy for Quality Improvement in Health Care (National Quality Strategy).iv The rationale is that "[h]ealth care should give each individual patient and family an active role in their care. Care should adapt readily to individual and family circumstances, as well as differing cultures, languages, disabilities, health literacy levels, and social backgrounds." Examples of person-centered care could be ensuring that patients' feedback on their preferences, desired outcomes, and experiences of care is integrated into care delivery and enabling patients to effectively manage their care.

The NHQR has tracked a growing number of patient centeredness measures. Organized around the National Quality Strategy, the 2013 NHQR presents the following measures that relate to the goal to provide patient-centered care:

  • Adults and children who reported poor communication at the doctor's office (composite).
  • Adults who reported poor communication with nurses and doctors at the hospital.
  • Provider-patient communication among adults receiving home health care.
  • Provider's involvement of the patient in making treatment decisions.

The last measure also relates to the National Quality Strategy goal of patient engagement.

Findings

Patients' Experience of Care—Adults

Optimal health care requires good communication between patients and providers, yet barriers to provider-patient communication are common. To provide all patients with the best possible care, providers need to understand patients' diverse health care needs and preferences and communicate clearly with patients about their care.

Figure 6.1. Composite: Adults who had a doctor's office or clinic visit in the last 12 months who reported poor communication with health providers, by insurance, ages 18-64 and age 65 and over, and activity limitations, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: Civilian noninstitutionalized population age 18 and over who had a doctor's office or clinic visit in the last 12 months.
Note: For this measure, lower rates are better. Patients who report that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication. Basic activity limitations include problems with mobility, self-care, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life.

  • From 2002 to 2010, for adults ages 18-64, there were no statistically significant changes in the percentage of adults with any private insurance, public insurance, or no insurance who had a doctor's office or clinic visit and reported poor communication (Figure 6.1).
  • In all years, a significantly lower percentage of adults with private insurance reported poor communication with their health providers compared with adults who were uninsured and those with public insurance (in 2010, 7.3% compared with 16.8% and 13.9%, respectively).
  • In 2010, the percentage of adults age 65 and over reporting poor communication with their health providers was significantly higher for those with Medicare and other public insurance than for those with Medicare only or Medicare and private insurance (7.6% compared with 4.5% and 4.4%, respectively).
  • In 2010, adults with basic activity limitations (11.6%) and adults with complex activity limitations (13.4%) were more likely to report poor communication with health providers than adults with neither basic nor complex activity limitations (7.3%).

Also, in the NHDR:

  • In all years, Hispanics were significantly more likely than Whites to report poor communication.
  • In 2010, the percentage who reported poor communication was significantly higher for Black adults than for White adults.
  • In all years, poor and low-income adults were more likely than high-income adults to report poor communication with health providers.

Patients' Experience of Care—Children

Communication in children's health care can be challenging since the child's experiences are interpreted through the eyes of a parent or guardian. During a health care encounter, a responsible adult caregiver will be involved in communicating with the provider and interpreting decisions to the patient in an age-appropriate manner. Optimal communication in children's health care can therefore have a significant impact on receipt of high-quality care and subsequent health status.

Figure 6.2. Composite: Children who had a doctor's office or clinic visit in the last 12 months whose parents reported poor communication with health providers, by insurance and primary language, 2002-2010

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Source:Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: Civilian noninstitutionalized population under age 18 who had a doctor's office or clinic visit in the last 12 months.
Note: For this measure, lower rates are better. Parents who report that their child's health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

  • From 2002 to 2010, the percentage of children whose parents reported poor communication significantly decreased overall and for children with private insurance and children with public insurance (Figure 6.2). During the same period, the percentage significantly decreased for both primary language groups.
  • In 2010, the percentage of children whose parents reported poor communication was higher for those with public insurance only (6.6%) and for those with no insurance (5.6%) than for those with any private insurance (2.4%).

Also, in the NHDR:

  • From 2002 to 2010, the percentage of children whose parents or guardians reported poor communication significantly decreased among Hispanics, Blacks, and Whites.

Patients' Experience of Care—Hospital

Using methods developed for the CAHPS® (Consumer Assessment of Healthcare Providers and Systems) survey (Hargraves, et al., 2003), the NHQR and NHDR use a composite measure that combines three measures of provider-patient communication into a single core measure. The composite measure presented includes data on providers who sometimes or never listened carefully, explained things clearly, and respected what patients had to say. These data are presented separately for communication with nurses and communication with doctors.

Figure 6.3. Adult hospital patients who reported poor communication with nurses and doctors, by age, 2009-2012

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Source: Agency for Healthcare Research and Quality, Hospital CAHPS® (Consumer Assessment of Healthcare Providers and Systems) Survey, 2009-2012.
Denominator: Adult hospital patients.
Note: For this measure, lower rates are better. Poor communication is defined as responded sometimes or never to the set of survey questions: "During this hospital stay, how often did doctors/nurses treat you with courtesy and respect?" "During this hospital stay, how often did doctors/nurses listen carefully to you?" and "During this hospital stay, how often did doctors/nurses explain things in a way you could understand?"

  • In 2012, 4.9% of adult hospital patients reported poor communication with nurses during their hospital stay, and 5.0% reported poor communication with doctors (Figure 6.3).
  • From 2009 to 2012, the percentage of adult hospital patients who reported poor communication with nurses decreased overall and for all age groups.
  • In 2012, the percentage of patients who reported poor communication with nurses was lower for adults age 65 and over compared with those ages 18-44 (4.4% compared with 5.2%).
  • From 2009 to 2012, the percentage of adult hospital patients who reported poor communication with doctors decreased overall and for all age groups except 65 and over.
  • In 2012, patients ages 45-64 were more likely to report poor communication with doctors compared with those ages 18-44 (5.6% compared with 4.8%).

Also, in the NHDR:

  • In 2012, compared with Whites, all racial groups were more likely to report poor communication with nurses.
  • Blacks, American Indians and Alaska Natives, and patients of more than one race were more likely than Whites to report poor communication with doctors.

Figure 6.4. State variation: Adult hospital patients who reported poor communication with doctors, 2012

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Source: Agency for Healthcare Research and Quality, Hospital CAHPS (Consumer Assessment of Healthcare Providers and Systems) Survey, 2012.
Denominator: Adult hospital patients.

  • There was significant variation across the Nation in adult hospital patients who reported poor communication with doctors:
    • First (best) quartile: 3.1%-4.1%.
    • Second quartile: 4.2%-4.7%.
    • Third quartile: 4.7%-5.5%.
    • Fourth (worst) quartile: 5.5%-8.9%.

New! Patients' Experience of Care—Home Health Care

The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Home Health Care Survey (Home Health Care CAHPS Survey) was designed to measure the experiences of people receiving home health care from Medicare-certified home health care agencies. In April 2012, the Centers for Medicare & Medicaid Services began publicly reporting results from this survey on Home Health Compare to create incentives for home health agencies to improve quality of care and to provide patients with information to help them choose home health care providers.

The results presented here reflect data collected from a sample of patients who received home health care between October 2011 and September 2012.

Figure 6.5. Provider-patient communication among adults receiving home health care, by language spoken at home, 2011-2012

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Source: Centers for Medicare & Medicaid Services, Home Health Care CAHPS (Consumer Assessment of Healthcare Providers and Systems) Survey, 2011-2012.
Denominator: Adults who had at least two visits from a Medicare-certified home health agency during a 2-month look-back period. Patients receiving hospice care and who had "maternity" as the primary reason for receiving home health care are excluded.

  • In 2012, among adult home health care patients, about 80% reported that home health care providers always informed them about when they would arrive, always explained things in a way they could understand, and always listened carefully to them. About 90% reported that home health care providers always treated them as gently as possible and with courtesy and respect (Figure 6.5).
  • The percentage of adult home health care patients who answered "Always" was lower on all five measures for those who spoke a language other than English or Spanish at home compared with patients who spoke English.
  • Adult home health care patients who spoke Spanish at home were more likely to report that providers always listened carefully to them. However, the percentage was lower on the other four measures compared with patients who spoke English.

Also, in the NHDR:

  • Asian and American Indian/Alaska Native adult home health care patients were less likely than White patients to report that home health care providers always informed them about when they would arrive, always explained things in a way they could understand, and always listened carefully to them.
  • Compared with Whites, adult home health care patients in all other racial and ethnic groups were less likely to report that home health care providers always treated them as gently as possible and with courtesy and respect.

Patient and Family Engagement: Enabling Effective Patient Navigation and Management of Care

To effectively navigate the complicated health care system, health care providers need to give patients access to culturally and linguistically appropriate tools to support patient engagement. Culturally and linguistically appropriate services are important components of effective health care delivery. It is vital for providers to understand patients' health care needs and for patients to understand providers' diagnoses and treatment recommendations. Communication barriers can relate to language, culture, and health literacy.

Health literacy is the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions (HHS, 2000). Patients with limited health literacy are more likely to have difficulty understanding instructions and taking medication properly. In addition, communication barriers such as LEP are associated with lower quality of care and place patients at risk for poor clinical outcomes (Ngo-Metzger, et al., 2007).

About one-third of Americans are not "health literate" (Gazmararian, et al., 2003; Parker, et al., 2003). Individuals with inadequate health literacy incur higher medical costs and are more likely to have an inefficient mix of service use compared with those with adequate health literacy (Howard, et al., 2005). They may experience many difficulties, including:

Providers Asking Patients To Assist in Making Treatment Decisions

The increasing prevalence of chronic diseases has placed more responsibility on patients, since conditions such as diabetes and hypertension require self-management. Patients need to be provided with information that allows them to make educated decisions and feel engaged in their treatment. Treatment plans also need to incorporate their values and preferences.

Figure 6.6. People with a usual source of care whose health providers sometimes or never asked for the patient's help to make treatment decisions, by activity limitations, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: Civilian noninstitutionalized population with a usual source of care.
Note: For this measure, lower rates are better. Activity limitation status applies only to adults age 18 and over. Basic activity limitations include problems with mobility, self-care, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life.

  • From 2002 to 2010, the percentage of people with a usual source of care whose health providers sometimes or never asked for the patient's help to make treatment decisions decreased overall (Figure 6.6).
  • From 2002 to 2010, the percentage of adults whose usual source of care did not ask for their help in making treatment decisions decreased for all activity limitation groups.
  • In 2010, adults with basic activity limitations (17.4%) and adults with complex activity limitations (18.8%) were more likely than adults with neither basic nor complex activity limitations (12.5%) to have a usual source of care who did not ask for their help in making treatment decisions.
  • In all years, adults with basic or complex activity limitations were more likely than those with neither limitation to have a usual source of care who did not ask for their help in making treatment decisions.

Also, in the NHDR:

  • In 2010, Blacks and Hispanics were significantly more likely than Whites to have a usual source of care who did not ask for their help in making treatment decisions.

References

Anderson EB. Patient-centeredness: a new approach. Nephrol News Issues 2002;16(12):80-2.

Baker DW, Gazmararian, Williams MV, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health 2002;92(8):1278-83.

Baker DW, Parker RM, Williams MV, et al. Health literacy and the risk of hospital admission. J Gen Intern Med 1998;13(12):791-8.

Bechel DL, Myers WA, Smith DG. Does patient-centered care pay off? Jt Comm J Qual Improv 2000;26(7):400-9.

Beck, RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract 2002;15(1):25-38.

Berkman, N, DeWalt D, Pignone M. Literacy and health outcomes. Summary. Evidence Report/Technology Assessment No. 87. Rockville, MD: Agency for Healthcare Research and Quality; 2004. AHRQ Publication No. 04-E007-1.

Berry LL, Seiders K, Wilders SS. Innovations in access to care: a patient-centered approach. Ann Intern Med 2003;139(7):568-74.

DiMatteo MR The role of the physician in the emerging health care environment. West J Med 1998;168(5):328-33.

Gazmararian JA, Williams MV, Peel J, et al. Health literacy and knowledge of chronic disease. Patient Educ Couns 2003;51(3):267-75.

Hargraves JL, Hays RD, Cleary PD, et al. Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 adult core survey. Health Serv Res 2003;38(6 Pt 1):1509-27.

Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med 2005;118(4):371-7.

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001a.

Institute of Medicine. Envisioning the National Health Care Quality Report. Washington, DC: National Academy Press; 2001b.

Little P, Everitt H, Williamson I, et al. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ 2001;323(7318):908-11.

Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med 2007;22 Suppl 2:324-30.

Office of Minority Health. Think cultural health: bridging the health care gap through cultural competency continuing education programs. Washington, DC: U.S. Department of Health and Human Services. Available at: http://www.thinkculturalhealth.hhs.gov. Accessed September 10, 2013.

Øvretveit, J. Do changes to patient-provider relationships improve quality and save money? A review of the evidence about value improvements made by changing communication, collaboration, and support for self-care. London, UK: The Health Foundation; 2012.

Parker RM, Ratzan SC, Lurie N. Health literacy: a policy challenge for advancing high-quality health care. Health Aff (Millwood) 2003;22(4):147-53.

Rhoades DR, McFarland KF, Finch WH. Speaking and interruptions during primary care office visits. Fam Med 2001;33(7):528-32.

Scott TL, Gazmararian JA, Williams MV, et al. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care 2002;40(5):395-404.

Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000;49(9):796-804.

U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. Washington, DC: Government Printing Office; 2000.

U.S. Department of Health and Human Services. Language Access Plan 2013. Available at: http://www.hhs.gov/open/execorders/2013-hhs-language-access-plan.pdf (PDF File, 376 KB). Accessed September 10, 2013.

U.S. Department of Health and Human Services, Office for Civil Rights. Guidance to federal financial assistance recipients regarding Title VI prohibition against national origin discrimination affecting limited English proficient persons. 68 Fed Reg 47311-47323; August 8, 2003. Available at: http://www.gpo.gov/fdsys/pkg/FR-2003-08-08/pdf/03-20179.pdf (PDF File, 215 KB). Accessed September 10, 2013.

U.S. Department of Justice, Civil Rights Division, Federal Coordination and Compliance Section. Common language access questions, technical assistance, and guidance for federally conducted and federally assisted programs. Washington, DC; August 2011. Available at: http://www.lep.gov/resources/081511_Language_Access_CAQ_TA_Guidance.pdf (PDF File, 411 KB). Accessed September 10, 2013.

Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes. Ann Intern Med 2013;158(8):573-9.

White House. Executive Order 13166: Improving access to services for persons with limited English proficiency. 65 Fed Reg 50121; August 16, 2000. Available at: http://www.gpo.gov/fdsys/pkg/FR-2000-08-16/pdf/00-20938.pdf (PDF File, 259 KB). Accessed September 10, 2013.

Williams MV, Baker DW, Honig EG, et al. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest 1998;114(4):1008-15.

Williams MV, Baker DW, Parker RM, et al. Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998 Jan 26;158(2):166-72.


i For example, Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, may require the practitioner or hospital to provide language interpreters and translate vital documents for limited-English-proficient persons. Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794, may require the practitioner or hospital to provide sign language interpreters, materials in Braille, and/or accessible electronic formats for individuals with disabilities.
ii This free online educational program (available at www.thinkculturalhealth.hhs.gov) is accredited for Continuing Medical Education credits for physicians, as well as Continuing Education Units for physician assistants, nurse practitioners, registered nurses, social workers, and emergency response personnel.
iii National CLAS Standards Factsheet available at https://www.thinkculturalhealth.hhs.gov/Content/clas.asp
iv Available at http://www.ahrq.gov/workingforquality/reports.htm.


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Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Chapter 6. Patient Centeredness. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/nhqrdr/nhqr13/chap6.html

 

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