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.
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.
Multicultural health standards around the world
Around themulticultural health policy world in 80 minutes (or less)
Julia Puebla Fortier Executive DirectorDiversityRx – Resources for Cross Cultural Health Care www.diversityRx.org
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
Migrants Indigenous people Foreign workers RefugeesMinorities Medical tourists Foreign brides International students Expat professionals
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
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
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
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
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
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.
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
National Committee forQuality 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
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
Performance measures for culturalcompetence 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
California state law and regulations:SB 853 (2003)Health plans (insurance schemes) required to:periodically evaluate the linguistic needs of their enrolleepopulationsmaintain policies and procedures on access language assistanceservicesinstruct staff on the use of the language assistance servicesmonitor operations and services to ensure compliancesubmit a one-time "Cultural Appropriateness Report”
Lines of accountabilityState law >> Department of Managed Health Care >> Health Plans (insurance schemes) >> In house or contracted hospitals, clinics, services, group practices, individualproviders
Audit (2011)State Department of Managed Health Care is legallyrequired to audit implementation and report to thelegislature43 health plans, ranging in size from 10,000 enrollees tomore than 1 millionUsed survey audit tools to evaluate complianceReviewed consumer complaints
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
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
Small and specialized plans (dentaland 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.
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
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
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 individualhttp://www.health.vic.gov.au/cald
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
Link to quality and safetyFour domains of quality and safety as per the Victorianclinical governance policy framework (2009)Organisational effectivenessRisk managementConsumer participationEffective workforce
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
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
Achievements and promisingpractices 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.
Achievements and promisingpractices 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.
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
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
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.
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