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unpublished literature sources to provide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
| |
