I.
ASSESSING CULTURAL COMPETENCE
A.
About the Project
"How do we know cultural
competence when we see it?" is the central
question that prompted the Health Resources
and Services Administration (HRSA) to
sponsor a project to develop indicators
of cultural competence in health care
delivery organizations. Throughout the
nation, a growing consensus is emerging
about the nature and importance of cultural
competence as an essential component of
accessible, responsive, and high quality
health care. However, the pursuit of cultural
competence in health care delivery organizations
is constrained, in part, by the health
field's lack of systematic approaches
and tools for assessing cultural competence--that
is, for gauging its presence, level, quality,
and contribution to good health and health
care.
This
project aimed to contribute to the methodology
and state-of-the-art of cultural competence
assessment. The product - An Organizational
Cultural Competence Assessment Profile
- builds upon previous work in the field,
such as the National Standards for Culturally
and Linguistically Appropriate Services
(CLAS) , and serves as a future building
block that advances the conceptualization
and practical understanding of how to
assess cultural competence at the organizational
level.
The specific objectives
of this project were to: 1) develop an
analytic framework for assessing cultural
competence in health care delivery organizations;
2) identify specific indicators that can
be used in connection with this framework;
and 3) assess the utility, feasibility
and practical application of the framework
and its indicators. The project was implemented
through a contract with The Lewin Group,
Inc. HRSA's Office of Minority Health
and Office of Planning and Evaluation
provided both oversight and substantive
input to the project.
The project team employed several methods
to reach these objectives. The first was
a synthesis of over 120 published and
unpublished literature sources to provide
a resource document for the field and
to inform the project team's initial decisions
in developing an Assessment Profile. The
results of this review are presented in
an interim project report entitled,
Measuring Cultural Competence in Health
Care Delivery Settings: A Review of the
Literature. This report, available
at http://www.hrsa.gov/omh,
provides documentation that supports the
approach taken in this project. This documentation
is not repeated in this companion final
report.
Another important aspect of this project
was the input of an organized Technical
Expert Panel (TEP) comprised of individuals
with widely recognized expertise on issues
related to cultural competence (Appendix
A). The TEP was not a consensus
panel, but rather a group of advisors
that shared information, insights, and
opinions on an ongoing basis through meetings
and written commentary.
The project team also held discussions
with (or received input from) a range
of private- and public-sector persons
knowledgeable about cultural competence
and measurement who served as key informants
on the content of the Assessment Profile
(Appendix B).
Further, the project included input from
a Workgroup of HRSA's Cultural Competence
Committee (Appendix
C).
Finally, the project team
made site visits to best practice settings,
i.e., health care delivery sites that
have been recognized for their innovations
in cultural competence. Visits were made
to both HRSA-funded and non-HRSA-funded
sites, including: Betances Health Unit,
Inc; Community Health of South Dade, Inc.;
International Community Health Services;
Kaiser Permanente, San Francisco; Multnomah
County Health Department; South Cove Community
Health Center; and Sunset Park Family
Health Center Network (Appendix
D). These sites varied in size,
auspices, populations served, and history
and breadth of cultural competence activities.
The visits were not evaluations of
the sites, but rather opportunities to
get practical, experience-based perspectives
about assessing cultural competence and
the utility and feasibility of the Assessment
Profile.
The project used an iterative process
in developing the Profile. In the first
stage, a preliminary assessment framework
and initial set of indicators were developed
based on the literature review. In the
second stage, the preliminary framework,
set of indicators, and related assumptions
were refined following feedback from the
Technical Expert Panel, the HRSA Workgroup,
and key informants. The framework and
indicators resulting from this second
stage were further revised based on advice
from the Technical Expert Panel members,
as well as input from a range of persons
during the site visits.
For the purposes of this project, cultural
competence is defined 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." In developing a
tool to assess cultural competence in
the context of health care, the project
team concentrated on the organizational
level rather than the individual level.
The project was undertaken with the following
perspectives. First, organizational cultural
competence is an integral component of
systematic patient-centered care and has
the potential to improve access to care,
quality of care, and, ultimately, health
outcomes. Second, organizations can serve
as the "engine" driving the
development and maintenance of individual
provider cultural competence by providing
the managers, policies, and systems to
support the realities of culturally competent
encounters. Further, organizational cultural
competence not only affects service delivery,
but can be a mechanism for maintaining
and increasing an organization's market
share among diverse cultural groups. Thus,
"cultural competence service delivery
is both a quality and business imperative"
that should be incorporated at every level
of an organization. Finally, the assessment
or measurement of cultural competence
is an important aspect of organizational
behavior and should be a regular management
function. The result of such assessment
is organizational learning that can lead
to continuous service and management improvements
by providing information for decision-making.
The Assessment Profile presented in this
report offers an approach to obtaining
such information.
B. About the Organizational
Cultural Competence Assessment Profile
The Assessment Profile
is an analytic or organizing framework
and set of specific indicators to be used
as a tool for examining, demonstrating,
and documenting cultural competence in
organizations involved in the direct delivery
of health care and services. The Profile
is most pertinent for organizations that
are community-oriented. For the purposes
of this project, "community"
is defined as the population residing
in the geographic areas served by or potentially
served by a health care delivery organization.
While this project was funded by HRSA,
the Profile has relevance beyond HRSA-funded
programs to other community-oriented health
care delivery organizations.
In answering the question "How do
we know cultural competence when we see
it?," the Profile addresses whether
an organization has or exhibits the particular
features that should be evident or manifest
in a culturally competent organization
across the spectrum of critical areas
or domains of organizational functioning.
Use of the Profile is most appropriate
for a health care delivery organization's
internal assessment of cultural competence.
At a general level, the Profile can help
organizations frame and organize their
perspectives and activities related to
the assessment of cultural competence.
More specifically, the Profile can be
used in routine performance monitoring,
regular quality review and improvement
activities, assessment of voluntary compliance
with cultural competence standards or
guidelines, and periodic evaluative studies.
The Profile is not intended to be prescriptive;
rather, it is designed to be adapted,
modified, or applied in ways that best
fit within an organization's context.
However, while the Profile can be used
in whole or in part, the full application
enables an organization to comprehensively
assess its level of cultural competence.
The Profile may also be of interest to
entities such as health plans, accrediting
bodies, oversight agencies, community
groups, and others interested in promoting
quality of care through cultural competence
at the direct care level because it provides
a potential way to define expectations
and standards and assess the extent to
which these are met. However, at the Profile's
current stage of development, it is not
recommended for use by external stakeholders
to formally evaluate health care organizations.
The Profile is presented in a tabular/matrix
form that classifies indicators by critical
domains of organizational functioning
and by whether the indicators relate to
the structures, processes, outputs, or
outcomes of the organization. The indicators
reflect the view that the assessment of
cultural competence should encompass both
qualitative and quantitative data and
assess progress or movement toward achieving
results, not just the end results. The
outcome indicators focus on intermediate
outcomes for which a plausible or credible
connection/attribution to cultural competence
can logically be made. Broader and more
ultimate outcomes, such as the elimination
of health disparities, are not included
in this Profile because of the multiplicity
and complexity of factors that can influence
such longer-term outcomes.
To develop the Profile, the project team
employed an additive process typically
used in developing assessment tools that
first involved the formulation of performance
areas to be assessed and then the development
of performance indicators for each area.
This work is a first step along a continuum
that includes further refinement of the
indicators, identification of particular
qualitative or quantitative measures for
each indicator, identification or development
of data sources and data collection instruments,
and formal field testing. The scope of
this project did not allow for these additional
steps. Thus, the Assessment Profile should
be considered a work-in-progress.
II. KNOWING CULTURAL COMPETENCE WHEN WE
SEE IT: COMPONENTS OF THE PROFILE
The Assessment Profile
has three major components: 1) domains
of cultural competence; 2) focus
areas within domains; and 3)
indicators relating to focus
areas, by type of indicator.
A. Domains and Focus
Areas: Where to Look for Evidence of Cultural
Competence
The project team identified seven domains
(or performance areas) for assessing cultural
competence. These are the critical arenas
or spheres in which cultural competence
should be evident or manifest in an organization.
These seven domains reflect to a great
extent, although not exclusively, the
underlying construct of cultural competence
in health care delivery organizations
and are areas to examine for evidence
of cultural competence. Within each of
the domains, the project team developed
several focus areas. Focus areas are the
substantive topic areas that characterize
the domain. They are more specific arenas
to examine for evidence of cultural competence
and form the particular focus for identifying
indicators. The Profile's domains are
described below.
Organizational Values:
An organization's perspective
and attitudes with respect to the worth
and importance of cultural competence
and its commitment to provide culturally
competent care.
Governance:
The goal-setting, policy-making,
and other oversight vehicles an organization
uses to help ensure the delivery of culturally
competent care.
Planning and Monitoring/Evaluation:
The mechanisms and processes used for:
a) long- and short-term policy, programmatic,
and operational cultural competence planning
that is informed by external and internal
consumers; and b) the systems and activities
needed to proactively track and assess
an organization's level of cultural competence.
Communication: The exchange
of information between the organization/providers
and the clients/population, and internally
among staff, in ways that promote cultural
competence.
Staff Development:
An organization's efforts to ensure staff
and other service providers have the requisite
attitudes, knowledge and skills for delivering
culturally competent services.
Organizational Infrastructure:
The organizational resources required
to deliver or facilitate delivery of culturally
competent services.
Services/Interventions:
An organization's
delivery or facilitation of clinical,
public-health, and health related services
in a culturally competent manner.
Exhibit 1 lists the
focus areas for each domain of the Profile.
Exhibit 1: PROFILE DOMAINS AND FOCUS AREAS
DOMAIN
|
FOCUS
AREAS |
Organizational
Values: An organization's
perspective and attitudes regarding
the worth and importance of cultural
competence, and its commitment to
providing culturally competent care.
|
- Leadership,
Investment and Documentation
- Information/Data
Relevant to Cultural Competence
- Organizational
Flexibility
|
Governance:
The goal-setting, policy-making, and
other oversight vehicles an organization
uses to help ensure the delivery of
culturally competent care. "
|
- Community
Involvement and Accountability
- Board
Development
- Policies
|
Planning
and Monitoring/Evaluation:
The mechanisms and processes used
for: a) long- and short-term policy,
programmatic, and operational cultural
competence planning that is informed
by external and internal consumers;
and b) the systems and activities
needed to proactively track and assess
an organization's level of cultural
competence. |
- Client,
Community and Staff Input
- Plans
and Implementation
- Collection
and Use of Cultural Competence-Related
Information/Data
|
Communication:
The exchange of information between
the organization/providers and the
clients/population, and internally
among staff, in ways that promote
cultural competence. |
- Understanding
of Different Communication Needs
and Styles of Client Population
- Culturally
Competent Oral Communication
- Culturally
Competent Written/Other Communication
- Communication
with Community
- Intra-Organizational
Communication
|
Staff
Development:
An organization's efforts
to ensure staff and other service
providers have the requisite attitudes,
knowledge and skills for delivering
culturally competent services. |
- Training
Commitment
- Training
Content
- Staff
Performance
|
Organizational
Infrastructure: The organizational
resources required to deliver or facilitate
delivery of culturally competent services |
-
Financial/Budgetary
- Staffing
- Technology
- Physical
Facility/Environment
- Linkages
|
Services/Interventions:
An organization's delivery or facilitation
of clinical, public-health, and health
related services in a culturally competent
manner. |
-
Client/Family/Community Input
- Screening/Assessment/Care
Planning
- Treatment/Follow-up
|
B. Indicators by Type: Specific Evidence
to be Used in Assessing Cultural Competence
Within each of the domains
and focus areas, the project team identified
specific indicators of cultural competence
in health care delivery organizations.
Indicators are the particular observable
or measurable characteristics of an organization
that signify cultural competence. The
indicators directly answer the question:
"How can cultural competence be monitored
and assessed?" by identifying the
specific items on which information is
to be gathered. The project team identified
only those indicators deemed as critical
and reasonable exemplars of organizational
cultural competence to minimize complexity
and facilitate the use of the Profile.
While the indicators included in no way
represent the universe of indicators possible
for each domain and focus area, they still
reflect a comprehensive view of cultural
competence. Indicators were also selected
because of their particular relevance
to cultural competence. For the most part,
more generic indicators of performance,
quality, or access are not included. Further,
the Profile contains indicators that are
either qualitative or quantitative in
nature. (Again, it is important to note
that the Profile does not present performance
measures, which typically specify
baselines and target values for those
indicators that are quantifiable.)
Indicators in the Profile were classified
into four types: 1) structure indicators,
2) process indicators, 3) output indicators,
and 4) intermediate outcome indicators.
Structure indicators are
used to assess an organization's capability
to support cultural competence through
adequate and appropriate settings, instrumentalities,
and infrastructure, including staffing,
facilities and equipment, financial
resources, information systems, governance
and administrative structures, and other
features related to the organizational
context in which services are provided.
Process indicators are used
to assess the content and quality of
activities, procedures, methods, and
interventions in the practice of culturally
competent care and in support of such
care.
Output indicators are used
to assess immediate results of culturally
competent policies, procedures, and
services that can lead to achieving
positive outcomes.
Intermediate outcome indicators
are used to assess the contribution
of cultural competence to the achievement
of intermediate objectives relating
to the provision of care, the response
to care, and the results of care.
The Profile presents structure, process,
and output indicators for each domain.
Intermediate outcome indicators are
assumed to cut across domains and, therefore,
are not categorized by domain. Instead,
intermediate outcome indicators are
categorized by perspective, i.e., by
whether they are organizational-level,
client-level, or community-level outcomes.
Exhibit 2 depicts the components
of the Assessment Profile.
Exhibit 2: ASSESSMENT PROFILE COMPONENTS
III.
KNOWING CULTURAL COMPETENCE WHEN WE SEE
IT: THE ASSESSMENT PROFILE
The complete Assessment Profile is provided
in Exhibit 3, Parts I and II. Part
I presents the structure, process
and output indicators by domain. Part
II presents the intermediate outcome
indicators by perspective. In reviewing
the Profile, several important factors
should be kept in mind. First, given the
multi-faceted and interconnected nature
of cultural competence, the domains tend
to overlap with one another and do not
suggest mutually exclusive categories.
Therefore, specific indicators might fit
well within more than one domain. However,
despite the interconnected nature of the
domains, the indicators are positioned
in the domain for which there is the most
relevance and applicability. The presence
of "shaded cells" in the Profile
matrix does not imply missing information,
but rather that the project team did not
identify any particularly salient indicators
for that cell. Whether to develop indicators
for these "shaded cells" in
the future should be determined based
on issues of salience, appropriateness,
and feasibility. In some cases, additional
indicators may not be warranted.
Part
I: Structure, Process and Output Indicators
DOMAIN:
Organizational Values
An organization's perspective
and attitudes regarding the worth and
importance of cultural competence, and
its commitment to providing culturally
competent care.
INDICATORS
FOCUS
AREAS |
STRUCTURE
PROCESS
|
STRUCTURE
PROCESS |
OUTPUT |
Leadership,
Investment, Documentation |
- Individual(s)
at executive level with responsibility
for implementing/monitoring cultural
competence plans/initiatives
- Team/committee
of mid- and high-level staff responsible
for coordinating cultural competence
(and diversity) activities
- Funding
related to cultural competence
activities
|
|
- Overall
investment in cultural competence
- Mission
statement addresses cultural competence
- Strategic
plan addresses cultural competence,
including a cultural competence
plan
- Business
plan addresses cultural competence
- Program
plans address cultural competence
- Staff
awareness/acceptance regarding
contents of relevant plans
- Client/community
awareness regarding contents of
relevant plans
- Materials
expressing the organization's
commitment to cultural competence
|
Information/
Data Relevant to Cultural Competence |
- Mechanisms
for collection of cultural competence-related
information/data (client- and
population-level)
- Mechanisms
for appropriate dissemination
of cultural competence-related
information/data
|
-
Conducts regular organizational
self-assessments regarding cultural
competence
- Requires/facilitates
regular individual provider assessments
regarding cultural competence
- Obtains
client-level cultural competence-related
information
- Conducts
regular community/needs assessments
- Evaluates
cultural competence-related activities
|
- Flow
and feedback of cultural competence-related
information/data for use in policy,
program, operations, and treatment
planning and implementation
|
Organizational
Flexibility |
|
- Systematic
and ongoing examination and use
of information/data relevant to
cultural competence
|
-
Administrative and service delivery
adaptations tailored to population
in service area, including adaptations
to improve access to care
|
Information/Data
Relevant to Cultural Competence"
may include the following: ethnic/racial
demographics, client language preference,
epidemiological data related to various
cultural groups served, community needs
assessment, etc.
Part I: Structure, Process and Output
Indicators (Cont'd)
DOMAIN:
Governance
The
goal-setting, policy-making, and other
oversight vehicles an organization uses
to help ensure the delivery of culturally
competent care.
INDICATORS
FOCUS
AREAS |
STRUCTURE
|
PROCESS
|
OUTPUT |
Community
Involvement and Accountability |
-
Diverse governing body or policy
influencing group, with representatives
from groups served
- Community
advisory committee(s), representative
of groups served
|
- Community
participants are provided financial
and other supports for their involvement
on governing board and advisory
committees
|
-
Percentage and retention of community
members on governing body and
advisory committees
- Reports
to stakeholders on cultural competence
activities/issues
|
Board
Development |
|
- Has
ongoing education of governing
body regarding cultural competence
|
|
Policies |
|
|
- Formal
cultural competence-related policies
exist regarding:
- personnel recruitment/retention
- training/staff development
-language ccess/communication
-cultural competence-related grievances/
complaints
- community/client input
|
Part I: Structure, Process and Output
Indicators (Cont'd)
DOMAIN:
Planning and Monitoring/Evaluation
The
mechanisms and processes used for: a)
long- and short-term policy, programmatic,
and operational cultural competence planning
that is informed by external and internal
consumers; and b) the system and activities
needed to proactively track and assess
an organization's level of cultural competence.
INDICATORS
FOCUS
AREAS |
STRUCTURE
|
PROCESS
|
OUTPUT |
Client/
Community and Staff Input |
- Membership
on relevant planning committees
of community participants that
represent groups served
- Membership
on relevant monitoring/review
committees of community participants
that represent groups served
|
- Process
for obtaining client/community
input in the development of cultural
competence-related plans
- Process
for obtaining staff input in the
development of cultural competence-related
plans
- Process
for obtaining client/community
and staff input in cultural competence-related
monitoring and evaluation
|
- Consumer
participation/satisfaction regarding
cultural competence-related planning
- Staff
participation/satisfaction regarding
cultural competence-related planning
|
Plans and Implementation |
|
|
- Planning
documents, including fiscal plan,
addressing cultural competence
issues
- Integration
and implementation of cultural
competence plan
|
Collection and Use of Cultural Competence-Related
Information/ Data* |
- Data
sources and systems that support
proactive cultural competence
planning at all levels (policy,
program, operations, treatment)
- Resources
and capacity to collect/manage/report
cultural competence-related information/data
|
- Uses
community/client cultural competence-related
data in planning (policy, program,
operations, treatment)
- Monitors/evaluates
implementation and results of
cultural competence plans/activities
as part of quality improvement
activities
|
- Timely
and accurate cultural competence-related
data
- Monitoring
and evaluation reports related
to cultural competence
|
*"Information/Data
Relevant to Cultural Competence"
may include the following: ethnic/racial
demographics, client language preference,
epidemiological data related to various
cultural groups served, community needs
assessment, etc.
Part
I: Structure, Process and Output Indicators
(Cont'd)
DOMAIN:
Communication
The exchange of information between the
organization/providers and the clients/population,
and internally among staff, in ways that
promote cultural competence.
INDICATORS
FOCUS
AREAS |
STRUCTURE
|
PROCESS
|
OUTPUT |
Understanding
of Different Communication Needs and
Styles of Client Population |
- System
for informing patients of right
to free interpretation/translation
services
- System
for identification and recording
of population's and client's language
preferences, level of proficiency,
and literacy
- System
for access to trained interpreters
- Curriculum
and training programs for interpreters
and staff
- Fixed
point of administrative responsibility
for cross-cultural communication
support system
|
Provides
for staff training regarding cross-cultural
communication
" Monitors and evaluates cultural
competence in organizational and provider
communications |
- Special
"communication" initiatives
- Universal"
language access
- Linguistically
competent services provided
- Staff
demonstrates/applies effective
communication styles with diverse
groups
|
Culturally
Competent Oral Communication |
- Mechanisms
for providing access to trained
interpreters
- Trained
bi-lingual staff
- Protocol(s)
for when and how to elicit sensitive
information from clients
- Policy
in place that minimizes the use
of family members as interpreters
|
- Provides
for training and testing of interpreters
and bi-lingual staff
- Provides
for staff training on use of interpreters
|
- Languages/dialects
of community available at point
of first contact and all levels
of interaction
- Extent
of use and timeliness of interpretation
service, including requests and
fulfillment of requests
- Client
understanding of interpreted material
- Low
interpretation errors
|
Culturally
Competent Written /Other Communication |
- Criteria
available for assessing capability
of vendors that translate materials
|
- Uses
a quality review mechanism to
ensure that translated materials
convey intended meaning
- Engages
in culturally appropriate dissemination
of written/other materials
|
- Signage,
administrative documents, health
information materials, and all
key written/other materials in
language of the groups served
- Written/other
material appropriate to literacy
level of populations served
- Client
understanding of written/other
materials
|
Communication
with Community |
Mechanism
for systematic and ongoing communication
with community |
Engages
in two-way communication with community
from which clients/potential clients
come/may come |
|
Intra-Organizational
Communication |
- Policies,
workplace design, and mechanisms
in place to promote integration
of staff of various backgrounds
|
- Processes
to promote effective communication
among diverse staff
|
- Staff
demonstrates cultural competence
in communications with co-workers
|
Part
I: Structure, Process and Output Indicators
(Cont'd)
DOMAIN: Staff Development
An organization's efforts
to ensure staff and other service providers
have the requisite attitudes, knowledge
and skills for delivering culturally competent
services.
INDICATORS
FOCUS
AREAS |
STRUCTURE
|
PROCESS
|
OUTPUT |
Training
Commitment |
- Has
training plan for staff development
in cultural competence
- Training
in cultural competence linked
to quality improvement efforts
(as core competency)
|
- Provides
basic/initial and periodic cultural
competence training for all staff
- Incorporates
cultural competence training into
overall staff training activities
- Consultation
provided on cultural competence,
upon request
- Offers
regular opportunities for staff
to interact with community
- Conducts
regular monitoring and periodic
evaluations of cultural competence
training efforts
- Disseminates
information on staff training
opportunities and policies
|
- Investment
(monetary and other) in cultural
competence training
- All
staff complete basic/initial and
periodic cultural competence training
|
Training
Content |
- Cultural
competence curricula address key
cultural competence-related knowledge,
skills, and attitudes (as generally
applicable and as related to specific
relevant groups)
- Cultural
competence curricula particularized
to roles of persons trained (e.g.,
clinical, front-line, administrative,
marketing, etc.)
|
- Assesses
cultural competence training needs
of staff
- Obtains
community input regarding staff
training
- Assesses
the quality of staff training
in cultural competence
|
- Staff
demonstrates cultural competence
in knowledge, skills, attitudes,
and behaviors (as generally applicable
and as related to specific relevant
groups)
|
Staff
Performance |
- Cultural
competence is a part of job descriptions
- System
of incentives (individual and
team) for cultural competence
behaviors/activities
|
- Assesses
staff performance regarding cultural
competence
- Staff
performance evaluations are conducted
in a culturally competent manner
|
Staff
performance (including self-efficacy)
in application of cultural competence
principles/practices
|
Part
I: Structure, Process and Output Indicators
(Cont'd)
DOMAIN: Organizational Infrastructure
The organizational resources
required to deliver or facilitate delivery
of culturally competent services.
INDICATORS
FOCUS
AREAS |
STRUCTURE
|
PROCESS
|
OUTPUT |
-
Person(s) designated to monitor
the need for additional resources
or funding
|
- Process
for enhancing resources related
to cultural competence (e.g.,
grant writing, fundraising activities)
|
- Overall
budgetary allocation and investment
in cultural competence activities,
aligned with strategic plan
|
- A
plan for recruitment, retention,
and promotion of staff representative
of the population(s) served
- Designated
staff responsible for cultural
competence implementation/activities
- Staffing
to facilitate client/community
outreach and communication
|
- Active
staff recruitment for diversity
and cultural competence
- Active
retention/promotion of culturally
diverse workforce
- Process
for assessing the quality and
cultural competence of relevant
contractors/vendors
|
- Diverse
staff at all levels
- Community
liaisons (e.g., ombudspersons,
community health workers, cultural
brokers)
|
- MIS
that includes/tracks cultural
competence-related information
on populations and clients served
- Range
of technology that facilitates
communication between clients/population
and health organization/providers
|
- Staff
is trained to use, collect, and
input data into the organization's
information system in a consistent,
standardized way
|
|
- Culturally
inviting and helpful environments
(e.g., décor, color coding,
literature, posters)
|
|
|
- Formal
and informal alliances/links with
community and other partners to
address cultural competence issues
|
- Formal
internal coordination to facilitate
delivery of culturally competent
care
- Obtains
and considers information on cultural
competence of referral sources
and partnering organizations
|
- Evidence
of appropriate use of/referral
to partners/alliance members
|
Part
I: Structure, Process and Output Indicators
(Cont'd)
DOMAIN: Services/Interventions
An organization's delivery
or facilitation of clinical, public-health,
and health related services in a culturally
competent manner.
INDICATORS
FOCUS
AREAS |
STRUCTURE
|
PROCESS
|
OUTPUT |
Client/Family/
Community Input |
- Policies,
protocols regarding client/family/community
input
|
- Obtains
client, family, patient advocate
input regarding care planning
and treatment, as appropriate
- Meets,
during treatment, with client's
family or advocate (as appropriate
and with client consent)
- Obtains
community input regarding community-level
interventions
|
- Care
and treatment plan agreed on by
client/family and amended with
client/family input, as appropriate
- Tailored
outreach and community health
education initiatives
|
Screening/
Assessment/ Care Planning |
- Community
and client assessment guidelines
and tools exist to elicit cultural
and demographic factors relevant
to health and health behaviors
- Appropriately
detailed data routinely available
re culture/language and needs/assets
of populations and clients served
- Mechanism
for keeping providers updated
on illness patterns and treatment
efficacy issues (e.g., ethnopharmacology)
relevant to groups served
|
- Identifies
community/client beliefs, practices
and culture-related factors
- Addresses
systematic cultural/ethnic factors
in screening/assessment/care planning
|
- Provider
compliance with assessment guidelines
related to cultural competence
- Focused
prevention/treatment/maintenance
plans reflecting cultural competence-related
factors
|
Treatment/
Follow-up |
- Practice
guidelines and treatment framework
that account for differences related
to culture
|
- Makes
accommodations to and integrates
client's traditional health beliefs
and practices, as appropriate
- Utilizes
community resources as treatment
partners, as appropriate
- Provides
client- and population-level health
education around issues that are
specifically relevant in the community
- Regularly
assesses treatment processes and
outcomes related to ethnic/cultural/language
groups as part of quality monitoring
and improvement program
|
- Individualized
interventions applied in a patient-
and family-centered fashion
- Patient
instructions (written and oral)
reflect cultural competence
- Care-facilitating
outreach to clients/population
from relevant cultural groups
- Public
health interventions reflecting
needs of population in service
area
" Culture-specific quality
assurance reports
|
Part
II: Intermediate Outcome Indicators
INTERMEDIATE
OUTCOME INDICATORS
ORGANIZATIONAL
PERSPECTIVE |
CLIENT
PERSPECTIVE |
COMMUNITY
PERSPECTIVE |
- Rate
of appropriate use of services
relative to need
- Retention
of clients/reduced attrition rates
- Reduction
in rates of broken appointments/no-shows
- Reductions
in misdiagnoses and inadequate
treatment plans
- Rates
of appropriate management of selected
chronic conditions
- Staff
satisfaction
|
-
Perceptions regarding:
- cultural competence of providers/organization
- how well organization meets
their needs
- Satisfaction
with care
- Knowledge/understanding
regarding prevention, diagnosis,
treatment plan
- Agreement/compliance/adherence
with treatment plan
- Medication
compliance/reduction in misuse
of medications
- Improved
management of selected chronic
conditions
- Increase
in healthy behaviors and prevention
practices/reduction in risky behaviors
|
- Opinions
about the organization and its
responsiveness to community needs
|
IV.
OBSERVATIONS AND CONCLUSION
The Assessment Profile builds on previous
work and evidence in the field, as documented
in the project's Review of the Literature,
and is informed by input from many individuals
with varying perspectives and expertise,
including service providers and managers,
researchers and analysts, policy makers,
and others interested in developing, monitoring,
and assessing cultural competence in health
care delivery organizations. Listed below
are several observations related to cultural
competence assessment and the Profile
that emerged from the site visits and
the discussions with the Technical Expert
Panel, HRSA Workgroup, and key informants.
A.
Key Observations
Assessment is Not an Isolated Event
- Commentators
generally agreed that the assessment
of cultural competence should not be
considered an isolated event, but rather
a continuous process that is emphasized
and integrated in an organization's
overall assessment activities. Cultural
competence assessment, like other significant
management activities, should be clearly
identifiable and targeted to garner
the leadership and resources required,
while being an integral part of an organization's
regular performance and quality assessment
activities.
Importance of Assessing Institutionalization
- Many
commentators indicated that it is important
to assess the "institutionalization"
of cultural competence in an organization,
i.e., the extent to which cultural competence
is an integral part of the organization's
service, management and business functions.
They noted that the Profile begins to
address this phenomenon given its scope
of indicators and the several indicators
relating to integration.
Validation of the Components of the
Profile
- The
perspectives and activities of the health
care sites visited for this project
give credence to the Profile's seven
evidence-based domains as appropriate
performance areas for assessing cultural
competence. The sites emphasized the
importance of assessing the domain of
Organizational Values as the necessary
precursor to culturally competent performance.
In particular, dedicated leadership
for championing and implementing cultural
competence and cultural competence-related
data collection and analysis were noted
as two critical indicators of an organization's
commitment to cultural competence.
- The
site visits also supported the credibility
of the Profile's focus areas and specific
indicators. Either through the range
of activities conducted or planned by
the sites or through site recommendations,
every indicator was confirmed as important
evidence of cultural competence. Sites
often suggested additional indicators
for the Profile that reflected what
they viewed as important to assess and
monitor.
- The
inclusion of structure, process, and
output indicators in the Profile was
considered a strength by the TEP, HRSA
Workgroup, key informants, and persons
at the sites. Individuals consistently
noted that it is just as important to
measure progress on the journey towards
cultural competence as well as the results
of cultural competence. There was similar
agreement that emphasis on intermediate
outcomes vs. ultimate outcomes was the
more appropriate focus for the Profile
because of the plausibility of attributing
these more proximate outcomes to cultural
competence-related activities.
Potential Uses of the Profile
- A
contribution of the Profile is the organizing
framework it provides and the ability
of organizations to use it to systematically
assess their cultural competence. The
Profile can assist organizations in
identifying the critical elements for
measuring cultural competence. Its application
can help organizations gauge the level
of their cultural competence and provide
guidance on steps to be taken to achieve
greater cultural competence. The fact
that the Profile is comprehensive, while
including substantial depth, was often
noted as valuable in providing a holistic
view of the complex construct of cultural
competence at the organizational level.
- In
addition to its use in structured quality
assurance and other performance measurement
activities, the value of the Profile
as a "readiness" tool in helping
organizations respond to mandates and
standards was highlighted during the
site visits. For example: one site reported
that the Profile helped it prepare for
an accreditation visit by the Joint
Commission on Accreditation of Healthcare
Organizations (JCAHO); another noted
its use of the Profile to understand
how well the site was doing relative
to the National Standards for Culturally
and Linguistically Appropriate Services
(CLAS).
- The
Profile is viewed as useful to organizations
serving multiple cultural/ethnic groups
as well as those serving a single cultural/ethnic
group. The Profile captures many generic
aspects of cultural competence that
are pertinent whatever the specific
population served. Even in serving a
single cultural group, intra-group diversity
and change should be taken into account
and assessed in ways suggested by the
Profile. Additionally, sites noted that
the Profile could be beneficial in assessing
their progress in adapting to the ever
changing demographics of their communities.
- The
Profile is potentially useful for organizations
at different levels of cultural competence
development. The site visits suggest
that more "mature" organizations,
in which cultural competence activities
and assessment are largely institutionalized
and integrated, could use the Profile
as a mental checklist to assure the
critical elements suggested by the Profile
are captured in their quality assessment
activities. Organizations that are at
earlier stages in their cultural competence
development might use the Profile in
more explicit cultural competence assessment
activities as they work toward institutionalization
and integration of cultural competence
activities.
- While
most applicable to organizations involved
in health care service delivery, with
further development, the Profile can
be used by organizations such as accrediting
bodies, to define standards of cultural
competence for use in evaluating health
care delivery organizations. When cultural
competence assessments become part of
the public domain through such external
assessments, their findings can create
opportunities for broader systems change.
Feasibility of Applying the Profile
- The
flexibility offered by the Profile contributes
to its practicality/feasibility. Organizations
can pick-and-choose one or more aspects
of the Profile for assessment depending
on where the organization is in its
stage of development or based on other
organizational needs and resources.
However, to fully assess cultural competence,
an organization should address or revisit
all the domains to understand the extent
to which they are culturally competent.
- Where
to start?" was a question raised
given the comprehensiveness of the Profile.
The TEP members and the literature suggest
a number of considerations for selecting
a starting point in the assessment of
cultural competence. These include taking
into account: the organization's assessment
of the importance of particular indicators,
the feasibility of implementing the
indicators, and the temporal order in
which cultural competence activities
will or have taken place.
- All
sites were engaged in some aspect of
tracking, monitoring or assessment that
mirrored aspects of the Profile. In
addition, the Profile's focus on structures,
processes, outputs, and outcomes is
a framework familiar to and used by
health care delivery organizations.
These factors and the ability to apply
the Profile in whole or in part make
application of the Profile less daunting
than it might be otherwise.
- Some
sites, however, noted that data-related
factors would affect their ability to
fully use the Assessment Profile. While
inadequacies in management information
systems, especially integration across
business and clinical functions, were
noted, the lack of "analytic capacity"
or persons to collect and analyze the
data was particularly highlighted as
a limiting factor. Such limitations
are, of course, not unique to an organization's
cultural competence assessment, but
apply more generally to performance
and quality measurement efforts.
" The relative lack of reliable
and widely accepted data collection
instruments, such as survey tools to
assess client perspectives, is also
recognized as a limitation. In addition,
ensuring that existing or future instruments
are developed and applied in a culturally
competent manner was noted as a challenge.
B.
Conclusion
The goal of this project
was to advance the ability of health care
organizations to recognize and assess
cultural competence in order to inform
their decisions about maintaining and
improving the management and delivery
of health care services to their communities.
Included in the project's interim report,
Measuring Cultural Competence in Health
Care Delivery Settings: A Review of the
Literature, is a listing of assessment
tools and evaluative models that document
previous and current attempts at assessing
cultural competence. The Cultural Competence
Assessment Profile presented in this final
report contributes to the assessment field
by offering a tangible and targeted approach
for conducting organizational assessments
and serves as another step in the development
of viable assessment tools. Additional
work is needed to take the Profile to
the next level. This would include further
refinement of the performance areas/domains
and indicators, definition and validation
of performance measures, identification
or development of data sources and data
collection instruments, and field testing
the Profile. Feedback from the Technical
Expert Panel, key informants, and the
health care delivery sites indicates that
the Profile provides a solid foundation
for further development. The feedback
also suggests that the Assessment Profile
can be useful even in its current form
as an organizing framework, a "readiness"
tool, and a guide to an organization's
own development of indicators and measures
of cultural competence.
C.
Appendix
Acknowledgements
The Lewin Group extends a special acknowledgement
and thanks to the co-authors of this report,
Willine Carr, DrPH, Senior Staff
Fellow, Office of Planning and Evaluation
and Jeanean Willis, DPM, Senior
Public Health Analyst, Office of Minority
Health. As the HRSA Project Officers for
this project, Drs. Carr and Willis provided
the leadership, guidance, and substantive
input to make this a truly collaborative
effort. Both served as strong advocates
of HRSA's mission to increase the visibility
of cultural competence as a mechanism
for ensuring the delivery of high quality
health care services. Their vision, insight,
and dedication guided the development
of a product that undoubtedly will serve
to further advance the field of cultural
competence measurement.
We also want to acknowledge the invaluable
contributions of the project's Technical
Expert Panel (Appendix
A), experts who served as key informants
(Appendix B),
the workgroup of HRSA's Cultural Competence
Committee (Appendix
C), and the staff from the seven sites
that graciously participated in our site
visits (Appendix
D). Their work on behalf of cultural
competence is exemplary, and they are
truly leaders in the field.
We also acknowledge two former members
of The Lewin Group project team, Susanna
Ginsburg, MSW and Yolanda Partida, Ph.D.,
who were instrumental in the initial development
of this project.
.Prepared
for:
The Health Resources and Services Administration
U.S. Department of Health and Human Services
Parklawn Building
5600 Fishers Lane
Rockville, Maryland 20857
Prepared
by:
The Lewin Group, Inc.
Karen W. Linkins, Ph.D.
Sharrie McIntosh, MHA
Johanna Bell
Umi Chong, MBE
.April
2002
|