Hector Ortiz - Creating Health Equity by Implementing Culturally and Linguistically Appropriate Services

Communicating in a Small World:
Creating Health Equity by
Implementing Culturally and
Linguistically Appropriate Services
March 12-13, 2015
Hector Richard Ortiz, Ph.D.
Communicating in a Small World

Overarching Goal – To develop continued
education opportunities for public health
officials, clinical staff and patient populations
to better understand culture, diversity,
inclusion and health equity.
Overarching Goal

Culture: Traditions, behaviors, attitudes,
languages, thoughts, beliefs, values and ways
of communication with any group of people.
Culture acts like a template, shaping our
behavior and beliefs from generation to
generation.
What is Culture?

Culture is comprised of:
• History/identity
• Norms and values
• Artifacts and products
• Basic assumptions
• Language
• Customary behaviors
• Beliefs
• Thought patterns
What is Culture?

Three dimensions of culture:
“Universal” refers to ways in which all people in
all groups are the same.
“Group differences” refers to the traits a
particular group of people have in common and
how they are different from every other group.
“Personal” describes the ways in which each of
us is unique. We may even be different than
others in our group on a personal level.
Dimensions of Culture

Intercultural Communication
A form of interpersonal communication where
cultural influences are sufficiently great and
may interfere, distort or result in
miscommunication and/or lack of
understanding.
What is Intercultural Communication?

Diversity
• Diversity are the differences that comprise an
individual, group or organization.
Diversity implies:
• Mosaic of people, variety of backgrounds,
diverse value systems, different beliefs,
several perspectives
What is Diversity?

Primary elements of diversity:
• Age, gender, color, ethnicity,
national origin, physical and mental
ability, sexual orientation.
Secondary elements of diversity:
• Appearance, beliefs, faith,
education, family, income, attitude,
personal experiences and language
structure.
Dimensions of Diversity

Diversity and inclusion can allow people to see
everyone as part of the larger community,
and accept that everyone has skills and
knowledge that can contribute to the whole.
An inclusive and diverse environment should
recognize, affirm and value the worth of every
person, and recognize the dignity of all
individuals.
Diversity and Inclusion

Inclusion implies, but it is not limited to,
attract, hire, develop, engage and promote a
diverse workforce in the different fields and
decision-making processes.
Affirmative action, diversity and inclusion are
not the same.
Diversity and Inclusion

Culture: Integrated patterns of traditions,
behaviors, attitudes, languages, thoughts,
beliefs, values and ways of communication in
any group of people.
Competence: Capacity to function efficiently
and effectively as individuals and
organizations within the context of personal
and group differences.
What is Cultural Competence?

Cultural competence is a set of behaviors and
skills, attitudes and policies, to enable efficient
and effective internal and external work in
cross-cultural interactions.
Cultural and linguistic competence involves
individuals and programs that are compatible
to a consumer's cultural beliefs, practices and
languages needs.
What is Cultural Competence?

Health inequities
● Health inequities or health disparities
exist when one population or group of
people experience worse health outcomes
or a lesser quality of health care when
compared to other populations.
● These differences are often caused by
societal, economic or environmental
factors, such as poor housing, poverty or
discrimination.
What are Health Inequities?

• In the USA, access to quality, affordable
and preventive care is not consistent across
the country and inadequate for the least
healthy populations.
• Some health disparities includes, chronic
diseases, access to care, child mortality,
premature deaths, mental and oral health.
Who Suffers From Health Inequities?

What are Enhanced National CLAS Standards
• Enhanced national CLAS standards were
approved by the Department of Health and
Human Services (HHS) in 2013 as a blueprint
to help providers improve the quality of care
in serving diverse communities.

Enhanced CLAS Standards Promote Health Equity
Health equity is the attainment of the highest
level of health for all people, independently of
their race, ethnicity, origin, color, gender, age,
socioeconomic status, sexual identity or
expression.
(U.S. Department of HHS Office of Minority Health,
2011)

Social Determinants of Health
External conditions influencing health
outcomes are known as the “social
determinants of health.” They are the
circumstances in which people are born, grow,
live, work and age.
Factors such as jobs, the environment, health
care, transportation, food security, education
and housing, are examples of social
determinants.

Civil Rights and Equitable Health Care
Dr. Martin Luther King, Jr., identified health
inequity as the most harsh form of
discrimination saying “Of all the forms of
inequality, injustice in health care
is the most shocking and inhumane.”

Health Inequity Awareness
• Providers may order fewer diagnostic tests
for patients of different cultural
backgrounds because they may not
understand or believe the patient’s
description of symptoms. On the other
hand, more diagnostic tests may be ordered
to compensate for not understanding a
patient.

Health Inequity Awareness
• African-Americans may be less likely to be
referred for cardiac catheterization than
whites, when presenting with identical
symptoms.
• Hispanics who have a lower overall
incidence of breast, oral cavity, colorectal
and urinary bladder cancers, will experience
death rates from these conditions, similar to
that of the majority population.

The Cost of Inequity
• The economic cost of health inequities in
the United States is significant.
• It has been estimated that the combined
cost of health complications and subsequent
deaths due to inadequate and/or inequitable
care is $1.24 trillion (LaVeist, Gaskin and
Richard, 2009).

CLAS Standards Reduce Inequities
• The standards that define culturally and
linguistically appropriate services are known
by the acronym “CLAS.”
• The provision of CLAS is one of the easiest
ways to reduce health equities, improve
health outcomes and reduce health care
costs.

CLAS Standards Reduce Inequities
• The national CLAS standards are intended to
advance health equity, improve quality and
help eliminate health care disparities.
• Health care that meets CLAS standards have
been progressively recognized as effective in
improving the quality of care and services.
(Beach, et al., 2004; Goode, Dunne and Bronheim, 2006)

CLAS Standards Mandates
CLAS Mandates:
Title VI, Civil Rights Act, 1964
Title VI of the Civil Rights Act of 1964 ‐ § 601
ensures nondiscrimination in federally assisted
programs and states that “No person in the
United States shall, on the grounds of race,
color or national origin, be excluded from
participation in, be denied the benefits of or be
subjected to discrimination under any program
or activity receiving federal financial
assistance.”
http://www.hhs.gov/ocr/civilrights/resources/laws/index.html

CLAS Standards Mandates
• The HHS health resources and services
administration found that health
professionals who lack cultural and linguistic
competency can be found liable under tort
principles (2005) for failing to follow the
national CLAS blueprint.

Evolution of CLAS Standards
• Original national CLAS standards were
developed in 2000 by the HHS Office of
Minority Health building upon Title VI of the
Civil Rights Act of 1964.
• To better reflect the objectives of the
Affordable Care Act (ACA) of 2010, CLAS
standards underwent an enhancement
initiative from 2010 to 2012. The
enhanced national CLAS standards of 2013
address new developments and trends.

CLAS/Enhanced CLAS
Expanded
standards
National CLAS
standards
National enhanced CLAS
standards 2013
Culture
Defined in terms of racial,
ethnic and linguistic groups
Defined in terms of racial,
ethnic and linguistic groups, as
well as geographical, religious
and spiritual, biological and
sociological characteristics
Audience Health care organizations Health and health care
organizations
Health Definition of health was
implicit
Explicit definition of health to
include physical, mental, social
and spiritual well-being
Recipients Patients and consumers Individuals and groups

Enhanced CLAS Standards Principals
The enhanced national standards for CLAS
in health and health care can be classified
into four categories:
1. Principal standard
2. Governance, leadership and workforce
3. Communication and language
assistance
4. Engagement, continuous improvement
and accountability

Enhanced CLAS Standards
Principal Standard
(Standard 1)
1. Provide effective, equitable, understandable
and respectful quality care and services that
are responsive to diverse cultural health
beliefs and practices, preferred languages,
health literacy and other communication
needs.

Governance, Leadership and Workforce
(Standards 2, 3 and 4)
2. Advance and sustain organizational
governance and leadership that promotes
CLAS and health equity through policy,
practices and allocated resources.

3. Recruit, promote and support a culturally and
linguistically diverse governance, leadership
and workforce that are responsive to the
population in the service area.

4. Educate and train governance, leadership and
workforce in culturally and linguistically
appropriate policies and practices on an
ongoing basis.

Communication and Language Assistance
(Standards 5, 6, 7 and 8)
5. Offer language assistance to individuals who
have limited English proficiency and/or other
communication needs, at no cost to them, to
ensure timely access to all health care and
services.

6. Inform all individuals of the availability of
language assistance services clearly and in
their preferred language, verbally and in
writing.

7. Ensure the competence of individuals providing
language assistance, recognizing that the use
of untrained individuals and/or minors as
interpreters should be avoided.

8. Provide easy-to-understand print and multimedia
materials and signage in the languages
commonly used by the populations in the service
area.

Engagement, Continuous Improvement
and Accountability
(Standards 9, 10, 11, 12, 13, 14 and 15)
9. Establish culturally and linguistically
appropriate goals, policies and management
accountability, and infuse them throughout the
organization’s planning and operations.

and Accountability
(Standards 9, 10, 11, 12, 13, 14 and 15)
10. Conduct ongoing assessments of the
organization’s CLAS-related activities and
integrate CLAS-related measures into
measurement and continuous quality
improvement activities.

and Accountability
(Standards 9, 10, 11, 12, 13, 14 and 15)
11. Collect and maintain accurate and reliable
demographic data to monitor and evaluate the
impact of CLAS on health equity and
outcomes, and to inform service delivery.

and Accountability
(Standards 9, 10, 11, 12, 13, 14 and 15)
12. Conduct regular assessments of community
health assets and needs, and use the results
to plan and implement services that respond
to the cultural and linguistic diversity of
populations in the service area.

and Accountability
(Standards 9, 10, 11, 12, 13, 14 and 15)
13. Partner with the community to design,
implement and evaluate policies, practices
and services to ensure cultural and linguistic
appropriateness.

and Accountability
(Standards 9, 10, 11, 12, 13, 14 and 15)
14. Create conflict and grievance resolution
processes that are culturally and linguistically
appropriate to identify, prevent and resolve
conflicts or complaints.

and Accountability
(Standards 9, 10, 11, 12, 13, 14 and 15)
15. Communicate the organization’s progress in
implementing and sustaining CLAS to all
stakeholders, constituents and the general
public.

The enhanced national CLAS standards align other
regulations and guidelines such as:
• HHS Action Plan to Reduce Racial and Ethnic
Health Disparities (HHS, 2011).
• National Stakeholder Strategy for Achieving
Health Equity (HHS National Partnership for
Action to End Health Disparities, 2011).
Plans and Strategies Aligned With CLAS

The Joint Commission’s Roadmap for
Hospitals (2010)
Hospital’s ability to advance culturally
competent care rests on its “state of
organization readiness.”
Organizational readiness requires:
• use of qualified language interpreters;
• addressing patient communication needs;
• collection of race and ethnicity information;
• strengthening nondiscrimination issues.

The Joint Commission on Provision of Care
PC.02.01.21: The hospital effectively
communicates with patients when providing care,
treatment and services.
 EP 1: The hospital identifies the patient’s oral
and written communication needs, including
the patient’s preferred language for discussing
health care.

The Joint Commission on Provision of Care
 EP 2: The hospital communicates with the
patient during the provision of care,
treatment and services in a manner that meets
the patient’s oral and written communication
needs.

The Joint Commission on Record of Care
RC.02.01.01: The medical records contain
information that reflects the patient's care,
treatment and services.
 EP 28: The medical record contains the
patient's race and ethnicity.

The Joint Commission on Human Resources
HR.01.02.01: The hospital defines staff
qualifications.
 EP 1: The hospital defines staff qualifications
specific to job responsibilities.
 Note 4 in EP 1 requires that individuals who
provide interpreting and translation services
have defined qualifications and competencies.

The Joint Commission on Patient Rights
RI.01.01.01: The hospital respects, protects
and promotes patient rights.
 EP 29: The hospital prohibits discrimination
based on age, race, ethnicity, religion,
culture, language, physical or mental
disability, socioeconomic status, sex, sexual
orientation and gender identity or expression.

Regulations and Laws Aligned with CLAS
ACA of 2010
• Expands initiatives to increase racial and
ethnic diversity.
• Requires health plans to implement activities
to reduce health disparities, including the
use of language services, community
outreach and strengthens cultural
competency trainings.

The Significance of ACA
• The passage of ACA (2010) increased
awareness of health disparities.
• The law requires health plans to take
measures to reduce health disparities.
• ACA expands initiatives to recruit individuals
from diverse racial and ethnic backgrounds.
• ACA also strengthens cultural competency
training in health and health care.

CLAS Legislation Map
Denotes legislation requiring (WA, CA, CT, NJ,
NM) or strongly recommending (MD) cultural
competence training that was signed into law.
Denotes legislation that was referred to
committee and/or is currently under
consideration (NY, OH, IN, KY, GA, MO, OK, AZ).
Denotes legislation that died in committee or
was vetoed ( IL, IA, FL, TX, CO).
This information is located on the website of the Office of Minority Health.
https://www.thinkculturalhealth.hhs.gov/content/legislatingclas.asp

Final Thoughts
Coming together is a beginning;
keeping together is progressing;
working together is success!
- Anonymous
Thank you!
¡Gracias!

Hector Ortiz - Creating Health Equity by Implementing Culturally and Linguistically Appropriate Services

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