Get Prepared Its Time for a Culture Audit

May 2014

Karen Beverly-Ducker, MA, CCC-A, CAE

There are many different types of audit, some more familiar than others. An income tax audit involves an Internal Revenue Service review of reported income and the determination that all credits, deductions, and exemptions taken were appropriate. A financial audit involves a review of accounting records, internal controls, policies, cash holdings, and the other financial areas of a company or business. A Medicare recovery audit is conducted to uncover and prevent Medicare fraud, waste, and abuse. A patient care audit is often used as part of a quality improvement initiative and includes a review of medical records to measure the quality of patient care. The ASHA certification maintenance audit is a random evaluation of an individual's records and is used to verify compliance with the standards for certification maintenance.

Independent of the type of audit being conducted, there is often a certain level of anxiety associated with the activity. However, performing your own audit in advance can help to identify areas in need of focus and to prepare for any reviews that may be conducted by others.

Culture Audit

The cultural values and preferences of all individuals involved as well as those of the setting or environment can impact all aspects of a "business." For example, a consumer information initiative, marketing strategy, training program, advertising campaign, or personnel policy that is highly successful in one culture may be wholly ineffective in a different culture and have wide-reaching impact on outcome, compliance, and overall goodwill.

A culture audit involves the review of the cultural values and preferences of the overall setting, organization, or business. In the professional service delivery setting, this includes both how the professional service provider and the client/patient respond to, for example, clinical services, strategies, products, practices, policies, communications, and recommendations in light of cultural influences. The culture audit is designed to define work behaviors and approaches to service delivery, identify problems with the system, and remove barriers to professional service delivery.

A culture audit also involves the overall review of the cultural values and preferences of the professional service provider as well as the client/patient. This includes an examination of the wide array of differences as well as similarities across cultural variables from the two perspectives.

For the professional service provider, this process is also referred to as cultural competence. "Developing cultural competence is a dynamic and complex process requiring ongoing self-assessment and continuous expansion of one's cultural knowledge. It evolves over time, beginning with an understanding of one's own culture, continuing through interactions with individuals from various cultures, and extending through one's own expansion of knowledge. Professional competence requires that audiologists and speech-language pathologists practice in a manner that considers each client's/patient's/caregiver's cultural and linguistic characteristics and unique values so that the most effective assessment and intervention services can be provided." (ASHA, n.d.)

Performing a Culture Audit

A formal, customized culture audit typically consists of five phases—needs awareness, diagnosis, planning, action, and evaluation—and provides action plans based on results. The audit may be conducted by an external, independent consultant or completed internally by an advisory team consisting of staff members and patients/clients. During the diagnosis phase, the advisory team identifies how the data will be gathered; collects, reviews, and analyzes the data; and then outlines the desired culture. During the planning phase, the advisory team develops the plans for intervention and change. During the action phase, the culture begins to move toward its desired or envisioned future. This phase often requires change in the organization's systems—technology, structure, decision making, budgeting, and managing. During the evaluation phase, the organization assesses the impact of its culture on its performance.

In preparation for (or in the absence of) a formal customized culture audit, valuable information can be gathered and considered. In general, focus may be directed to three major areas—policies, procedures, and processes; service providers; and clients/patients served—to assess the current cultural state. Each area should be reviewed with consideration given to how the area may be impacted by cultural variables, such as race, ethnicity, culture, language, dialect, national origin, gender, gender identity or expression, sexual orientation, age, religion, socioeconomic status, and/or ability.

Questions for guidance include:

Policies, Procedures, and Processes

Does the professional setting have a vision statement, a mission statement, and strategic goals that reflect inclusiveness and a commitment to culturally competent care?
Do current policies, procedures, and processes hinder or support the vision, mission, and strategic goals?
Do current policies, procedures, and processes support efforts to accomplish work or do they impede progress?
Is written information provided in languages in addition to English?
Is the facility accessible by individuals with different needs and levels of ability?
Are the professional services accessible in terms of language(s) used? Does this extend to the first point of contact-for example, when scheduling?
Are there scheduling options, such as evening and weekend hours?
Are materials and resources available that are appropriate for working and communicating with individuals who do not use spoken English?
Are financial resources available to support the acquisition of materials, assessment tools, etc. that meet diverse cultural and linguistic needs?
Is a teamwork approach used to deliver services, and does that approach include and acknowledge the valuable role of different team members (e.g., the audiologist, audiology assistants, interpreters, etc.)?
Are human resources dedicated to meeting the needs of diverse populations?

Service Providers

Are professional service providers prepared to provide services to diverse populations?
How do individual service providers describe the culture of the professional setting?
How do individual service providers display and share their cultural identities?
Are there opportunities for individual service providers to assess, understand, share, and celebrate their respective cultures?
Are there specific strategies for recruiting and retaining diverse staff members?
Do the knowledge and skill sets of staff members mirror the needs of the patient/client population?
Is there funding specifically dedicated for professional education in the area of cultural and linguistic diversity?
Are professional service providers aware of the regulatory requirements, mandates, and national standards regarding the provision of language services?
Do staff members know how to access needed resources (i.e., interpreter services, telephone or video language services) for individuals who do not use spoken English?
Do service providers have the needed skills to explore client/patient perspectives and cultural and religious beliefs related to health, illness, and treatment?
Does the staff "photo" reflect diversity? Is this diversity reflected across all positions?

Clients/Patients

What is the typical profile of the patients/clients seen?
Does the typical patient/client profile reflect that of the community?
How often is community-level demographic data collected?
How is information gathered about the client/patient perspective?
Do clients/patients have the opportunity to share their individual cultural influences, practices, and preferences?
Is consumer satisfaction data gathered related to cultural and linguistic services?
What are the physical signs of the culture in the professional setting?
Do photos, artwork, brochures, etc. reflect a variety of people and family groupings so that clients/patients "see themselves"?
Does signage convey information in a variety of forms?

The Value of a Culture Audit

The objective of the culture audit is to help gain an understanding of the current culture. As with all audits, a culture audit represents that moment in time. Culture is dynamic and should be periodically reviewed. The results from the culture audit will either confirm the efficacy of the current culture or help to identify areas in need of change. All information gathered-both the positive aspects and the more challenging aspects-are needed for the creation and maintenance of the desired culture and to ensure appropriate service delivery for diverse populations.

About the Author

Karen Beverly-Ducker serves as the director, Multicultural Resources, at the American Speech-Language-Hearing Association (ASHA) and as the ex officio to ASHA's Multicultural Issues Board. Her area of focus is the influence of cultural and linguistic factors on the many aspects of professional service delivery. Contact her at kbeverlyducker@asha.org.