This presentation reviews key standards, performance measures, and laws related to multicultural health and cultural competence from the US, Australia, and Scotland. Presented at the EU COST ADAPT meeting, Amsterdam, October 2012.
2. Julia Puebla Fortier
Executive Director
DiversityRx – Resources for Cross Cultural Health Care
www.diversityRx.org
3. DiversityRx:
Improving health care for a diverse world
Policy development Working with:
Research Hospitals and health departments
Information dissemination Universities
Education and training Philanthropic foundations
Government agencies
International organizations
4. Migrants Indigenous people
Foreign workers
Refugees
Minorities
Medical tourists
Foreign brides
International students
Expat professionals
5. Policy tools:
Laws and regulations, standards, resolutions,
performance measures, accountability frameworks
U.S. – CLAS Standards, Joint Commission, health reform
State laws and regulations: California
Australia: Cultural responsiveness framework
Scotland: Policy tools and lessons learned
6. U.S. CLAS Standards (2001)
Categories of interventions
Culturally Sensitive Interventions
Cultural competence education
Race, ethnic and linguistic concordance
Community health workers and culturally competent
health promotion
Language Assistance
Bilingual services, oral interpretation, translated
written materials
7. Categories of interventions (con’t)
Organizational Supports for Cultural Competence
Management and policy strategies
Community engagement
Information and data for planning and evaluation
Appropriate ethics and conflict resolution processes
8. Review and enhancement process
(2010-12)
Review process: literature review, national public comment
period, advisory committee
Revised objective of standards:
advance health equity
improve quality
help eliminate health care disparities by providing a blueprint to
implement culturally and linguistically appropriate services
9. Expanded definitions
Culture: integrated pattern of thoughts, communications, actions,
customs, beliefs, values, and institutions associated, wholly or
partially, with racial, ethnic, or linguistic groups, as well as with
religious, spiritual, biological, geographical, or sociological
characteristics.
Health: including physical, mental, social, and spiritual well-being
Targeted audience: health care settings, such as hospitals, clinics,
and community health centers, as well as organizations that
provide behavioral and mental health, public health, emergency,
and community health services
10. New Standard:
Governance and Leadership
CLAS should be integrated throughout an organization.
Requires a bottom-up and a top-down
Organizational governance and leadership are key to
ensuring the successful implementation and
maintenance of CLAS.
11. The Joint Commission
Required accreditation process
Early interest in cultural, linguistic issues
Comparison of CLAS standards and JC standards
Hospital, Language and Culture study
Standards and implementation guide released in 2011
12. National Committee for
Quality Assurance
Voluntary standards and accrediting body for managed care plans
Test waters with CLAS awards program – highlight best practices
Multicultural Health Standards released this year
Focus on data collection, staff diversity/ cultural competence,
language services
13. National Quality Forum
Comprehensive voluntary framework and preferred
practices for measuring and reporting cultural
competency
45 preferred practices in 6 domains:
Leadership
Integration into management systems
Patient-provider communication
Care delivery structures
Workforce diversity and training
Community engagement
14. Performance measures for cultural
competence and disparities reduction
NQF endorsement of 12 performance measures, August 2012
Workforce development
Performance evaluation
Leadership commitment
Individual engagement
Cross cultural communication
Language services
Screening for and receipt of language services
Health literacy
Overall organizational cultural competence
(Race, ethnicity and language data collection toolkit previously
endorsed
Disparities reduction measures in late 2012
15. California state law and regulations:
SB 853 (2003)
Health plans (insurance schemes) required to:
periodically evaluate the linguistic needs of their enrollee
populations
maintain policies and procedures on access language assistance
services
instruct staff on the use of the language assistance services
monitor operations and services to ensure compliance
submit a one-time "Cultural Appropriateness Report”
16. Lines of accountability
State law >>
Department of Managed Health Care >>
Health Plans (insurance schemes) >>
In house or contracted
hospitals, clinics, services,
group practices, individual
providers
17. Audit (2011)
State Department of Managed Health Care is legally
required to audit implementation and report to the
legislature
43 health plans, ranging in size from 10,000 enrollees to
more than 1 million
Used survey audit tools to evaluate compliance
Reviewed consumer complaints
18. Findings
Ongoing need to educate health plans and their
providers about the requirements
Language services meet proficiency standards
Services made available at provider offices and
hospitals
Services are offered to all even when friends or family
can interpret
Educate enrollees about their rights to language
services and health plan obligations to provide them
19. Deficiencies
The failure to properly train provider groups and offices
on the plan’s language assistance program
requirements
The failure to arrange for the provision of language
assistance at all points of contact
The failure to ensure the proficiency of the interpreter
services provided to plan enrollees
20. Small and specialized plans (dental
and vision)
Majority of deficiencies
Smaller enrollment and fewer resources; proportionately more
individual provider offices
Need to
educate providers on their obligation to provide language
assistance
inform the public of the availability of language assistance
coordinate the arrangement of qualified interpreter services
within the plans’ health care delivery system
oversee and ensure the quality and timeliness of those services.
21. Compliance monitoring
Significant improvements needed:
Improve oversight of the proficiency of bilingual
office staff
Refine criteria used in audit tools to verify proficiency
Ensure that providers comply with the plan’s
language assistance program
22. Are services getting to the patients?
Patients have ability to directly request interpreters
when making appointments, but mostly do not
Health plan pilot project:
Web based appointment system for providers, direct
link to booking interpreter
Of 100 providers, only 6 agreed to try it
2 of these reported positive outcomes and
satisfaction
Only 20 came to a luncheon to report results and
promote the system
23. State of Victoria, Australia:
Cultural responsiveness framework (2009)
Link access & equity and quality &
safety
Embed cultural responsiveness
into core planning
Different levels of intervention:
systemic, organisational,
professional and individual
http://www.health.vic.gov.au/cald
24. Six Standards
A whole-of-organisation approach
Leadership demonstrated
Accredited interpreters available
Inclusive practice in care planning, eg: dietary, spiritual,
family, attitudinal, and other cultural practices
Consumer/community involve in the planning,
improvement
Staff professional development opportunities to
enhance their cultural responsiveness
25. Link to quality and safety
Four domains of quality and safety as per the Victorian
clinical governance policy framework (2009)
Organisational effectiveness
Risk management
Consumer participation
Effective workforce
26. Lessons learned
Consultation and testing the draft framework and
standards with health services prior to implementation
Drawing from an international research and evidence
base
Setting standards to work towards over time
Linking standards to existing reporting requirements
Building upon successful practices and integrated with
key policy and legislative frameworks
Aspiration can foster motivation
27. Opportunities and challenges
Achievements are a foundation to build upon
Some standards are aspirational measures and sub-
measures used to guide achievement
Data: some not currently collected or recorded
Coordination with other cultural diversity reporting
criteria and requirements across health service
Implementing a whole-of-organisation training
approach
28. Achievements and promising
practices
Alignment of cultural responsiveness with quality and safety in
health care delivery.
Promoted a higher standard of planning for culturally responsive
healthcare.
Health services have a 3-4 year Cultural Responsiveness Plan linked
to strategic plan and other policy and reporting frameworks.
Significantly, many health services have exceeded the minimum
requirements by additionally addressing all sub measures within
the framework.
29. Achievements and promising
practices
Legitimisation and contextualisation of cultural responsiveness as
a core health service activity
Monitoring of standards and development of benchmarks over
time
Adaptation of framework by a variety of health care organisations
Development of innovative research activities and service delivery
models and resources at a health service level.
30. Scotland: Policy tools
2000 Race Relations Amendment Act
a duty to demonstrably promote equality by
publishing both plans and progress
Ethnicity and Health (Fair for All) Policy
Energizing the organization, leadership
Demographics, understanding the populations under
consideration.
Access and adaptation of service delivery
Human resources, equality in employment
Community engagement
31. Scotland: Policy tools (con’t)
National Resource for Ethnic Minority Health (2003-08) >>>
Directorate of Equalities and Planning
Merged into overall NHS structure
Integrating the issue of ethnic disparity with other equality strands
such as age, gender, religion, sexual orientation and disability.
Checking for Change, Case Studies for Change
Organization-level performance measurement toolkit, progression
from basic to advanced level
Model practices collected from around the country
Equity Impact Assessment
Performance of NHS regional boards
32. Successes Challenges
Strong and clear policy framework Implementation
with performance measures
Insufficient monitoring
Robust data collection, analysis
and research Sparse budgets
Free interpretation services Competing priorities
Targets for diversifying workforce Mainstreaming projects into
routine service
Staff training opportunities
Maintaining engagement between
Patient accommodations: menus, the statutory and voluntary sectors
religions spaces, signage
Altering service delivery
Community outreach programs,
population-specific interventions Winning hearts and minds.
33. Observations
Transferability across different contexts: paradigms, resources,
politics, social attitudes, level of development
Find balance between highly specific and streamlined approaches,
different tools for different tasks
Dangers of the checkbox mentality
How to affect the intangibles
Does what’s being measured relate to desired outcomes
Mainstreaming v. combined approach v. targeted agenda
Rules or suggestions: the need for accountability
Leadership imperative
Good morning. It’s a great honor to be in Australia for this conference, and to have the opportunity to share some reflections with you about improving the quality of health care for culturally diverse populations through standards and policy development. I’ve decided to use the metaphor of a journey to talk about this topic today, although the journey is also a real and personal one. Over the last 15 years, I’ve had the opportunity to take a literal and philosophical trip through the health policy world of several continents, from the U.S. to Europe to Japan. I’ve been fortunate to observe or participate in policy development in many settings, and witness the evolution of multicultural health from an obscure marginal topic to one that is on the agenda of many national governments and international organizations. Today I will share some insights and offer a global context for the important work you are doing here in Australia.
My name is Julia Puebla Fortier, and I am the executive director of the non governmental organization DiversityRx – Resources for Cross Cultural Health Care. In many ways, I am an example of the multicultural world that many of our patients come from: I’m the child of a Mexican immigrant mother and 2 nd generation American father. I grew up in the United States, and have lived in England, Switzerland, France, and now Japan.
The mandate of DiversityRx is to improve the accessibility and quality of health care for a diverse and globalized world. We support those who develop and provide health services that are responsive to cultural and linguistic differences presented by mobile, minority and indigenous populations. Active in the United States, Europe and now Asia, DiversityRx has worked with hospitals, universities, philanthropic foundations, government agencies and international organizations to develop policy, raise awareness and develop strategic collaborations. Through research, conferences and the internet, we collect and disseminate information about model programs and policies around the world.
What happens when a person gets sick outside their own country or home town is an increasing global phenomena. The impact is faced by every hospital and health care provider, sometimes multiple times a day. There are 214 million international migrants – that would be the 5 th most populous country in the world. 922 million business and recreational travellers. 10.5 million refugees and 27 million internally displaced people. Millions of men and women who leave their homes to work or get married in another country. Increasing incentives to develop services for medical tourists. And because they speak different languages or have different cultural practices, minorities and indigenous people often experience the same barriers as mobile populations. Now, I’d like to make a distinction between vulnerable populations and more privileged populations. There may be more incentive to service some populations groups and disincentives to serve others. But many of the needs are the same, and can be met by some of the same interventions. This is the globalized patient. And as health care providers, policymakers, researchers and advocates, we are called to serve them.
The key to long-term improvements in the delivery of care to to the globalized patient lies in formal systems of programs and policies in mainstream health organizations, as opposed to ad hoc, short term individual projects. These strategies must engage health staff from all disciplines and areas of responsibility, and address all levels of health planning, service delivery, management, and governance. There is an emerging field of policies being implemented around the world that address these issues, from professional accreditation to policies and regulations to international initiatives. Let’s look at a few examples.
Patchwork regullatory strructure in the US – some public, some private and required, some private and voliuntary. Leads to fragmentation and lack of clarity, but not static and so open to innovation and experimentation, and eventual integtation into binding policy structures.
Thank you for your attention today. I would be very happy to discuss your own experiences and questions about how to adapt health systems for the globalized patient. Please feel free to contact me by email at [email_address] And don’t forget to download the resource document.