Background: Health inequities and disparate treatment outcomes arise from complex, multi-level factors. At the individual level, these inequities are often linked to lower engagement among minoritized patients and a lack of cultural curiosity from providers. The Cultural Formulation Interview (CFI) offers a validated, standardized approach to initiating culturally responsive care. Previous research has identified clinician uncertainty as a key barrier to implementing cultural assessments. To address this challenge and enhance cultural assessment in a fast-paced pediatric integrated primary care (IPC) setting, a Quality Improvement (QI) framework was used to increase the frequency and standardization of cultural assessments as a strategy to reduce individual-level health inequities.

QI Procedure/Team Composition: An iterative Plan-Do-Study-Act (PDSA) process was employed to guide implementation. This approach gathered clinical stakeholder feedback, identified barriers, tested solutions, and supported ongoing modifications.

A five-member QI team was formed, meeting every 2–3 months. The team included three master’s-level behavioral health consultants (BHCs), one doctoral-level supervisor, and one predoctoral intern BHC who served as facilitator. All members worked within pediatric IPC across general and specialty outpatient settings. Cultural assessment efforts focused on patients aged 12–21 and caregivers of patients aged 1–21.

Over the first six months, the team met three times. Meeting agendas were based on protocols outlined by the Institute for Healthcare Improvement. Verbal and written feedback were collected to evaluate cultural assessment frequency, perceived barriers, and facilitators. Meeting transcripts were qualitatively coded to inform procedural changes and refine cultural assessment practices.

QI Results: Initial feedback indicated that clinicians valued cultural assessment for clinical decision-making. Baseline barriers identified were workflow challenges, limited time, and clinician concerns. Proposed solutions included reminders, electronic health record (EHR) shortcuts for standardized questions, and supervision discussions. In the first cycle, all clinicians reported asking cultural assessment questions, collecting clinically useful information, and increasing their frequency of cultural inquiry compared to baseline. Cultural questions were most commonly asked during weight management intakes, but less consistently across other referral reasons.

Despite initial improvements, use of standardized questions remained low (12%), and completion rates remained inconsistent (below 50%) across three QI cycles. Barrier themes persisted, particularly around the feasibility of using standardized questions with every patient's initial follow-up visits. In response to results and team feedback, the team tested workflow modifications, integrated cultural discussions into supervision, developed specific cultural questions for weight management referrals, and created EHR shortcuts.

Discussion: Findings suggest that while clinician-led QI efforts can initially enhance cultural assessment, sustained improvements may require program-level support. Persistent barriers, such as workflow inconsistencies and clinician concerns, remained despite team members recognizing the importance of cultural assessment and implementing proposed solutions. Future strategies could include cultural assessment training, dedicated time for brief IPC intakes, and chart reviews to monitor assessment rates.