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.

1. Around the
multicultural health policy world
in 80 minutes (or less)

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

34. Contact: rcchc@aol.com