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Cultural Competence Self Assessment Protocol for Health Care Organizations and Systems (Dennis Andrulis et al.)

We can measure organisational cultural competence using simple pencil-and-paper self-assessment for example the Cultural Competence Self Assessment Protocol for Health Care Organizations and Systems (Andrulis et al. 2005). It was developed by Dennis Andrulis, Thomas Delbanco, Laura Avakian and Yoku Shaw-Taylor, is an innovative approach to assessing organizational cultural competence. The protocol builds upon the Georgetown University Child Development Center's Continuum of Cultural Competency.

The following is taken directly from the instrument and can be found at http://erc.msh.org/provider/andrulis.pdf 


The cultural competence protocol is a tool that can be used by health care providers, including hospitals and clinics, to conduct organizational assessments of their cultural competence. It is particularly useful for services involving racially and ethnically diverse populations. The protocol’s questions are organized according to four cornerstones of cultural competence:

  • a health care organization's relationship with its community;
  • the administration and management's relationship with staff;
  • inter-staff relationships at all levels;
  • the patient/enrollee-provider encounter.

The protocol allows organizations to score responses and then place themselves on a five point spectrum of cultural competence, ranging from inaction to a fully realized "learning" organization.

The protocol has many uses. For example, it can serve as a formal organization-wide review tool or as a department- or clinic-specific assessment instrument. While the protocol is intended to be administered as a self-assessment, it is possible to use it in conjunction with an external organization. In addition, the protocol’s format requires actively engaging a broad spectrum of health care staff and encourages the use of focus groups with patients/enrollees. In all, the protocol can provide a health care organization an opportunity to assess what it does well in providing care to diverse populations, where its gaps lie, and how it could create an agenda for improving its services.

Notes

PURPOSE

There  are  several  reasons  why  a  healthcare  organization  may  wish  to  conduct  an  audit  of  its cultural competence.   First, it may want to validate its understanding of the ethnic and cultural composition of its patient and employee populations. Further, it may seek to identify the unique attributes  of  a  given  cultural  group  to  ensure  access,  appropriate  treatment  and  effective communication between providers and patients.   Additionally, the audit may reveal opportunities for the organization to make itself more attractive to diverse populations, thereby enhancing its marketing capabilities as well as strengthening its ties to community. Most important, the very act of conducting the self-assessment is a statement to the workforce, patients and community that the organization values diversity and desires to increase its cultural competence.

 

HOW TO CONDUCT THE SELF-ASSESSMENT

A.        Create a task force of stakeholders

Ultimately, quite a number of people will be involved in the process because you will want to scan the breadth and depth of the organization.  However, the audit should be led by a small committee that represents certain key functions or departments. A typical self-assessment team consists of 8 to 12 people.

On  the  audit  team  should  be  individuals  who  can  access  and  interpret  data  addressing  the composition  of  the  patient  and  staff  population.  Team  members  may  come  from  finance, admitting,   patient   registration,   human   resources,   information   systems,   or   administration. Additionally, there should be individuals whose jobs are directly concerned with ethnic/cultural issues, i.e. diversity coordinators, translators/interpreters, social workers, community relations and employee relations specialists, and clergy. Different clinical disciplines should also be represented: doctors, nurses, therapists. The team may benefit by inviting patients or representatives of your community as members.  The team itself should also reflect ethnic/cultural diversity.

 

B.        Select a task force leader

Who  serves  as  leader  of  the  assessment  team  is  an  important  decision.  He  or  she  should  be  an individual  who  is  well-positioned  within  the  organization—one  who  has  access  to  people  at  all levels  and  information  from  all  sources.  He  or  she  must  be  credible,  respected,  and  generally regarded as sensitive to diversity issues.  Equally important is the explicit support for this initiative from the CEO and other prominent leaders. They can demonstrate such support through written and verbal communication, as well as by devoting time and other resources needed to conduct the audit.

STEPS IN THE SELF-ASSESSMENT PROCESS

There  are  generally  five  steps  in  the  self-assessment.  However,  organizations  will  vary  the  time spent or depth of inquiry at various stages of the process.

 

Step 1  Organization

(a)  The CEO appoints the team leader and task force.

(b)  CEO and other organizational leaders affirm the project team’s charter.

(c)  The task force develops a timeline for the entire project.

(d)  Individual task force members take assignments.

Step 2  Completing the Questionnaire

(a)  Task force members determine who is best able to complete each section of questionnaire and takes responsibility for its completion.

(b)  Task force members discuss what supplementary materials may support the information provided in the questionnaire (e.g. patient information pamphlets) and take responsibility for obtaining them.

Step 3  Interviews

(a)  The task force reviews and discusses findings from the questionnaire. Based on those

results, the task force determines what individual or group interviews should be conducted to explore further some issues identified in the questionnaire or to clarify areas that are ambiguous.

(b)  Members of the task force decide who will complete each of the interviews. (Possible interview subjects and exploratory questions are suggested below.)

Step 4  Evaluation of Results

(a)  The task force reviews the data from the questionnaire and the interviews.

(b)  Drawing on the data and analyses, the team decides where the organization fits along the “spectrum of cultural competence.” Step 5  Report and Action

(a)  Depending on the charge given the team in Step 1, the task force discusses its findings with multiple audiences.  These findings are often offered in a written report to the CEO or a Board committee.

(b)  In addition to a self-assessment of overall cultural competence, the report will likely include specific recommendations for actions to be taken, identifying who would be accountable for taking the actions.


HOW LONG DOES THE SELF-ASSESSMENT TAKE?

Depending  on  the  availability  of  data  and  the  complexity  of  the  organization,  the  entire  self- assessment can be completed in three to six weeks. Completing the questionnaire and conducting the interviews can be simultaneous if desired.

 

THE INTERVIEWS

There is no magic number of interviews, but individuals from each of the following groups should contribute:

Board of Trustees               Dietitians

Administration                    Admitting and registration staff

Community leaders             Human Resources staff Patients                                            Marketing staff Translators/interpreters                                            Community Relations staff Social Workers                                            Clergy

Nurses                                 Maintenance/housekeeping staff

Physicians                           Public Relations staff Emergency Unit staff                                    Patient advocates Diversity trainers                                            Union leadership

Before  the  interviews  are  scheduled,  the  CEO  should  issue  a  general  announcement  about  the assessment,  its  purpose,  and  what  the  organization  will  do  with  the  results. Members  of  the committee should contact the interviewees, emphasizing that  each  interview  is  confidential  and  that results  will  be  shared  only  in  aggregate  form.  The  interview  will  generally  last  15  to  45  minutes,  and participants should be encouraged to bring along relevant data, materials etc. Invite them to show you materials such as patient information pamphlets, special menus, translated newsletters, etc.

In general, the interviews should elicit information about those policies and practices that impact on ethnic/cultural competence. They should identify both support and barriers to ethnic/cultural competence. Additionally, they provide the opportunity to learn about individuals opinions and attitudes  about  this  subject  and  to  explore  related  areas  that  may  not  be  covered  in  the questionnaire. Interview questions are suggested below. You will want to add or delete some based on your particular findings and interests. SUGGESTED QUESTIONS FOR INTERVIEWS*

The  following  are  questions  that  might  be  posed  to  individuals  both  within  and  external  to  the organization who are interviewed as part of the self-assessment process.

The purpose of the interview is to add the dimension of personal experience to the information gleaned from the questionnaire and to identify unexplored areas. While many of these questions are covered in the questionnaire, additional insights will be obtained as the interviewees address these questions in terms of their experience and the context of their jobs.

Along with data reported in the questionnaire, these answers will help your organization assess its overall cultural competence and identify steps for action.   These questions may be supplemented by  others  suggested  by  the  committee.  Also,  interviewees  may  wish  to  discuss  other  aspects  of diversity and/or share written materials with you.


QUESTIONS

1.   When you hear the term “cultural competence, what comes to mind?

2.   What are the most challenging priorities of the multi-ethnic and cultural nature of the healthcare organization?

3.   What are the major organizational obstacles (policies, organizational characteristics) inhibiting ethnic and cultural understanding among staff, patients, providers, etc.? What are the major organizational characteristics that enhance the multi-ethnic and cultural nature of the healthcare organization?

4.   As the healthcare organization has attempted to meet the needs of ethnic and cultural diversity, what issues have arisen (need for resources, conflict, etc.)?

5.   What mechanisms, if any, are in place that promote communication among different levels and departments of the healthcare organization in regard to issues of cultural competence?

6.   What has the healthcare organization done to provide the best care for the multi-ethnic and cultural patient population (e.g. educating providers in regard to different ethnic/cultural beliefs and practices; use of specific services—interpreters, community liaisons, etc.)?

7.   In what ways have you addressed the ethnic and cultural needs of patients as they receive care throughout the continuum (home health, social services, etc.)?

8.   What services, programs, etc. are available to staff regarding ethnic/cultural-related issues?

9.   In what ways are providers trained and helped to deal with ethnic and cultural issues (e.g. trained to recognize diseases common in certain populations, mechanisms and protocols by which providers can request assistance in dealing with ethnic/cultural patient issues and needs)?

10. What relationships does the healthcare organization have with particular community groups and how have these relationships affected the ethnic/cultural competency effort (community businesses under contract, initiatives with neighborhood health centers, etc.)?

11. What community outreach actions have been taken by the healthcare organization (e.g. health education programs, materials and forums for various ethnic/cultural groups, community support for patients of various ethnic/cultural backgrounds)?

12. In what ways are ethnic and cultural differences recognized throughout the healthcare organization (e.g. celebration of certain days, programs focused on specific health needs of a particular group)?

13. What, if any, ethnic/cultural professional programs are there to develop, as well as attract staff?  Are internships targeted toward ethnic professionals?  Mentoring programs? What are the challenges in developing and delivering these programs?

14. What government guidelines or regulations guide or influence your programs and initiatives regarding ethnic/cultural diversity and cultural competence?

15. What are the greatest strengths and the biggest concerns of the healthcare organization in regard to the delivery of care to and interactions with the multi-ethnic/cultural populations of its community?

16. What have you seen or would you like to see in terms of actual effects of ethnic/cultural initiatives on the work environment and on patient care?

17. What are your concerns about any of the ethnic/cultural activities undertaken by your organization?

*(Acknowledgment  is  given  to  Deborah  Dwork,  Employee  Relations  Director,  Beth  Israel

Deaconess Healthcare organization, Boston, MA, who developed many of the above questions for use in its self-assessment.)

 

HOW THE QUESTIONNAIRE IS ORGANIZED

The questionnaire is divided into three sections, each with distinct features.

Questions in Section 1 relate to the ethnic/cultural characteristics of the staff and organization. There  are  two  sub-sections  covering  the  following:  (a)  board,  staff,  and  patient/community profiles; and (b) healthcare organizational recognition of diversity needs.

Questions in Section 2 relate to healthcare organizational approaches to accommodating diversity needs  and  attributes.  There  are  three  sub-sections  covering  the  following  areas:  (a)  diversity training; (b) human resource programs; and (c) union presence.

Questions  in  Section  3  are  dedicated  to  healthcare  organizational  links  to  the  communities  you serve  as  well  as  patient  and  staff  diversity  initiatives.  This  section  is  divided  into  five  parts:  (a) healthcare  organizational  links  to  community;  (b)  organizational  adaptation  to  diversity;  (c) database systems and data development; (d) language and communication needs of patients and staff; and (e) business strategies attracting patients from diverse cultures.

USING THE RESULTS

This  self-audit  will  help  an  organization  evaluate  where  it  sits  within  a  “spectrum  of  cultural competence. However, it is important that the team completing this assessment not view it as a quiz with a set of perfect answers.  It is, rather, an opportunity to consider candidly the extent to which the healthcare organization is meeting the needs of diverse populations, both patients and those in the work force. The findings will, in themselves, suggest actions an organization may take to  improve  its  cross-cultural  competence.  The  results  of  this  internal  review  will  help  the healthcare organization gain a broad perspective of its policies, programs and procedures relevant to ethnic and cultural concerns.   Please refer to the accompanying scoring guide for data analysis and interpretation.


 

Questionnaire items

PART 1:            ETHNIC/CULTURAL CHARACTERISTICS

This section contains questions on the characteristics of your staff and the healthcare organization. Questions  relate  to  two  broad  areas:  staff  profiles  and  healthcare  organizational  recognition  of diversity needs.

PART 1A:         BOARD, STAFF AND PATIENT/COMMUNITY PROFILES

1.         Ethnic and Cultural Chara cteristics - For each of the five ethnic/cultural groups, please provide percentages, estimates or ranges for the past fiscal or calendar year.  Base responses on the past fiscal or calendar year. Please indicate whether (1) fiscal year: from                                                          

to___________,   or  (2) calendar year: from                        to                      

 

 

Administration / Management

Support Staff

Board

Members

Non-Physician

Providers

African-American*

 

 

 

 

Asian/Pacific Islander

 

 

 

 

Hispanic/Latino

 

 

 

 

European-American**

 

 

 

 

American Indian/ Eskimo/Aleut

 

 

 

 

Total 100%

 

 

 

 

* Includes persons of Caribbean descent and non-Hispanic

** Non-Hispanic

 

House Staff

Attending

Physicians

Patients by

Discharge

Community

Characteristics

African-American*

 

 

 

 

Asian/Pacific Islander

 

 

 

 

Hispanic/Latino

 

 

 

 

European-American**

 

 

 

 

American Indian/ Eskimo/Aleut

 

 

 

 

Total 100%

 

 

 

 

* Includes persons of Caribbean descent and non-Hispanic

** Non-Hispanic

 

2.         To what degree do your board members reflect the ethnic/cultural characteristics of your community?

 

1                      2                      3                      4                      5

almost a                                  somewhat                               not at all perfect match

 

3.         Has the administration identified ethnic/cultural competence as an organizational concern? Yes   No

 

4.         In what ways has the administration identified ethnic/cultural competence as an organizational concern?

 

 

 

 

5.         Has the board/administration adopted a mission or goals statement that explicitly

incorporates a commitment to cultural diversity?

 

Yes                        No (if no, skip to Q 8)

 

6.         To what degree does this statement reflect the current issues and concerns of the organization?

 

1                   2                      3                      4                      5

completely                            somewhat                               not at all

 

7.         What year was this done? Please attach the mission statement, or type in sections that address this.

 

Year                          


PART 1B:  HEALTHCARE ORGANIZATIONAL RECOGNITION OF DIVERSITY NEEDS

 

8.         What are the major organizational characteristics that inhibit ethnic and cultural understanding among staff, patients, providers? Attach extra sheets if necessary.

 

 

Administration/ Support Staff

Patients

Providers-Physicians/ Nurses

Characteristic

#1

 

 

 

Characteristic

#2

 

 

 

Characteristic

#3

 

 

 

For example:        Facilities are spread            Communication difficulties        Signage and across broad geography for non-English speaking patients communication problems

 

9.         To what degree are there strategies in place to recruit/retain actively a culturally diverse

management/administration?

 

1                      2                      3                      4                      5

high                               somewhat                            not at all

 

10.       To what degree are there strategies in place to recruit/retain actively a culturally diverse

support staff?

 

1                      2                      3                      4                      5

high                               somewhat                            not at all


11.       What are these strategies?

 

 

Management/ Administration

Support

Staff

Strategy #1

 

 

Strategy #2

 

 

Strategy #3

 

 

For example:               Minority search firm                              Mentoring

 

12.       Are ethnic and cultural practices of minority staff accommodated through:

 

(a)  Time off for religious observance?     Yes                  No

(b)  Dietary/Cafeteria preferences?

Yes

No

(c)  Holidays?

Yes

No

(d)  Other                                    

Yes

No

(please specify)

 

 

 

 

13.       Overall, to what degree does the healthcare organization accommodate needs and

preferences of ethnic and cultural staff?

 

1                      2                      3                      4                      5

completely                             somewhat                             not at all

 

14.       An organization can identify several ways to increase cultural competence.  Below a re potential initiatives and areas in which organizations address diversity.  To what extent has your healthcare organization identified these and other areas? Please use the following scale in responding.

 

1                      2                      3                      4                      5

great extent                            somewhat                          not at all

 

 

(a)  Awareness of cultural issues in establishing measures for attracting and retaining minority & female staff

 

 

(b)  Awareness of cultural issues in improving achieving outcomes related to

low birth weight, prenatal care utilization, immunization rates, etc.

 

 

(c)  Cultural awareness/participation is recognized as important factor in

decision making

 

 

(d)  Soliciting minority input in developing programs,  models, guidelinesand

training materials

 

 

(e)  Long-term commitment to achieving cultural competence has been

established

 

 

(f)  Other (please specify)

 

PART 2:            HEALTHCARE ORGANIZATIONAL APPROACHES TO ACCOMMODATING DIVERSITY NEEDS AND ATTRIBUTES

 

This  section  contains  questions  on  how  your  healthcare  organization  addresses  diversity  needs. Questions relate to diversity training, human resource programs and union presence.

 

PART 2A:         DIVERSITY TRAINING

 

15.       Are staff members educated regarding the special needs and characteristics of each other;

including the education of one ethnic/cultural group about another ethnic/cultural group?

 

(a)  Cultural beliefs                                                                             Yes                  No

(b)  Adherence to treatment regimens (e.g. dietary requirements)

Yes

No

(c)  Integration with patient-preference for alternative therapies

Yes

No

(d)  Gender roles

Yes

No

(e)  Other (please specify)                                                                  Yes                   No

If no to all of the above, skip to Q 20

 

 

16.       How are staff members educated, and how effective are these methods?

 

1                      2                      3                      4                      5 extremely                                   somewhat                                not effective effective

 

 

Yes/No

Effectiveness

Training

 

 

Orientation

 

 

Reading materials

 

 

 

17.       If yes to training above (Q16), is it mandatory or voluntary? Please check appropriate box.

If no to training above (Q16), skip to Q 20

 

 

Mandatory

Voluntary

If Voluntary, what is compliance rate

(percent)

All staff

 

 

 

All but physicians

 

 

 

Management

 

 

 

Support

 

 

 

Volunteers

 

 

 

Other

 

 

 

(please specify)

 

 

18.       Please rate the general impressions of effectiveness of the training initiatives:

 

1                      2                      3                      4                      5                       6 extremely                                  somewhat                                not beneficial  don’t know beneficial                       beneficial

 

(a) Workforce relationships                

(b) Staff-patient interactions               

(c) Patient adherence to treatment protocols               

 

 

19.       Does your organization conduct formal evaluations of training programs that include pre

and post measurements?

 

(a) Workforce relationships                      Yes                  No

(b) Patient adherence to

treatment protocols                       Yes                  No

 

If yes to any of the above, please attach findings from these studies.

 

PART 2B:  HUMAN RESOURCE PROGRAMS

 

20.       Does your healthcare organization have the following programs?

 

(a) Career development activities

Yes

No

(b) Succession planning

Yes

No

(c) Technical training

Yes

No

(d) Management development

Yes

No

(e) Other__________________________

Yes

No

(please specify)

 

 

 

If no to all of the above, skip to Q 24

 

 

21. If yes to any of the above (20), for which staff?                                           

 

 

22.       Do you have the following activities available?

 

(a) Mentoring

Yes

No

(b) Tuition reimbursement

Yes

No

(c) Personal counseling/

 

 

employee assistance programs                   Yes                  No

(d) Other                                                         Yes                  No

(please specify)

 

If no to all of the above, skip to Q 24

 

 

 

23.       If yes to any of the above (Q 22), how effective are those programs identified in Q 22 in contributing to organizational goals for ethnic/cultural staff, and to what extent do they participate?

 

1                      2                      3                      4                      5                        6 extremely                                  somewhat                                not beneficial  don’t know beneficial                                           beneficial

 

 

Effectiveness

Percent staff participation

Mentoring

 

 

Tuition reimbursement

 

 

Personal counseling

 

 

Employee assistance

 

 

Other

 

 

 

(please specify)

 

 

24.       With regard to ethnic/cultural staff at your organization, what trend do you observe over the last 5 years?

 

(a)  Discrimination charges are not increasing                              Yes                  No

(b) Retention of ethnic/cultural minorities is not a problem

Yes

No

(c) Promotions of ethnic/cultural minorities is not a problem

Yes

No

(d) Turnover is not a problem

Yes

No

 

 

25.       Are there human resource policies and procedures in place to address concerns or

complaints concerning unfair treatment in the area of ethnic/cultural issues?

 

Yes                        No       (if no, skip to Q 27)

 

26.       What are these human resource policies and procedures, and how effective are they?

 

1                     2                      3                      4                      5 extremely                                 somewhat                                not at all effective

 

Please attach policies and procedures if more space is required.

 

Description

Effectiveness

Policy and procedure  #

1

 

 

Policy and procedure  #

2

 

 

Policy and procedure  #

3

 

 

 

 

27.       Has the organization developed a special office or function to address ethnic/cultural diversity; for instance an O ffice of Diversity?

Yes      No (if no, skip to Q 30)

 

28.       Provide a list of principal duties.

 

(a)                                          (b)                                    ___   (c)                                        

 

 

 

29.       Please identify (a) where the responsibilities reside; and (b) the position title.

 

(a)                                                                                       

(b)                                                                                       

 

 

 

30.       Are there marketing initiatives to identify, select and retain minority staff?

 

Yes                        No (if no, skip to Q 32)

 

 

31.       What are these marketing initiatives? Provide example. (For instance, are there specific goals to recruit Asian speaking staff to strengthen the ability to reach Asian mothers?)

 

 

 

 

32.       Is there specific financial support for cultural diversity activities or programs?

 

Yes                        No (if no, skip to Q 35)

 

 

33.       This question is in three parts. Please provide responses in the table below (see next page).

(a)  How much money has been allocated to the following key areas of cultural diversity activities or programs? Please provide dollar estimates in column titled ‘Allocation.’

(b)  How beneficial have these programs been in achieving related objectives? In column titled

‘Benefits, please indicate whether they have been

1                      2                      3                      4                      5                       6 extremely                                            somewhat        not beneficial  don’t know beneficial              beneficial

 

Please base your responses on past fiscal or calendar year.

 

Allocation

Benefits

Staff Training

 

 

Community Based Outreach

(Clinical Programs)

 

 

Community Education

Programs

 

 

Other

 

 

 

 

(please specify)

 

34.       If the allocation has changed over the past fiscal or calendar year, by what percentage has it changed? Indicate whether change has been positive (+) or negative (-). If budget has not changed, skip to Q 35.

 

 

Change in allocation

Staff Training

 

Community Based Outreach

(Clinical Programs)

 

Community Education

Programs

 

Other

 

 

 

(please specify)

 

 

 

PART 2C: UNION PRESENCE

 

35.       Is your organization unionized?

 

Yes                        No (if no, skip to Q 40)

 

36.       Please provide the names of the unions represented.

 

1.                                 

2.                                 

3.                                 

 

4.                                  

 

5.                                  

 

6.                                  

 

 

 

37.       What functions or employee groups in the system are unionized? E.g. maintenance,

housekeeping.

 

1.__________________

2.__________________

3.__________________

 

4.__________________

 

5.__________________

 

6.__________________

 

38.       Please rate the impact of unions on promoting diversity within the organization.

 

1                      2                      3                      4                      5                       6 extremely                                            somewhat        not beneficial  can’t judge beneficial               beneficial

 

39.       If you circled (1) or (2) above, list programs or activities that reflect this involvement.

 

1.__________________         2.__________________         3.__________________

PART 3:            HEALTHCARE ORGANIZATIONAL LINKS TO PATIENTS AND THE COMMUNITIES YOU SERVE

 

Questions in this section are dedicated to healthcare organizational links to the communities you serve  as  well  as  patient  and  staff  diversity  initiatives.  This  section  is  divided  into  five  parts:  (a) healthcare  organizational  links  to  community;  (b)  organizational  adaptation  to  diversity;  (c) database systems and data development; (d) language and communication needs of patients and staff; and (e) business strategies attracting patients from diverse cultures.

 

PART 3A: HEALTHCARE ORGANIZATIONAL LINKS TO COMMUNITY

 

Questions in this section address your healthcare organization’s links to the communities you serve and the effectiveness of these linkages.

 

40.       This question is in three parts; use table below:

(a)        Identification of service links - please name up to four (4) groups/organizations with which your healthcare organization has substantial links. If more than four, please attach pages.

(b)       What are the service linkage activities - please describe activities in the space provided, or attach additional pages if necessary.

 

(c)        How effective are these linkages - please use the scale below.

 

1                      2                      3                      4                      5 extremely                                  somewhat                                not at all effective

 

Please identify Community Advocacy Groups with which you have links

Activities

Effectiveness

1

 

 

2

 

 

3

 

 

4

 

 


Q 40 continued

Activities

Please identify Local/State Provider

Associations

with which you have links

Effectiveness

 

1

 

 

2

 

 

3

 

 

4

 

Actvities

Please identify Ethnic/Cultural Newspapers

with which you have links

Effectiveness

 

1

 

 

2

 

 

3

 

 

4

 

Activities

Please identify Churches with which you  have links

Effectiveness

 

1

 

 

2

 

 

3

 

 

4

 

 

 

 

 


Q 40 continued

Please identify Schools with which you  have links

 

Activities                           Effectiveness

 

1

 

 

2

 

 

3

 

 

4

 

 

Please identify Business Groups with which you have links

Activities

Effectiveness

1

 

 

2

 

 

3

 

 

4

 

 

 

 

41.       How closely does your healthcare organization work with these external resources in

accomplishing diversity objectives?

 

1                     2                      3                      4                        5

a lot                                  somewhat                                      not much

 

42.       Does your healthcare organization engage in the following community outreach activities:

 


(a) Provide an ombudsman office to assist ethnic/cultural

populations?

If yes, how long have you had this activity? ______(in years)

Yes            No

 

If no, do you have plans to undertake this activity?                               Yes No

 

(b) Involve the community in planning/evaluating functions?

If yes, how long have you had this activity? ______(in years)

 

Yes            No

If no, do you have plans to undertake this activity?                               Yes            No

 

(c) Encourage staff to participate in community meetings?                    Yes            No

If yes, how long have you had this activity?______(in years)

 

If no, do you have plans to undertake this activity?                               Yes            No

 

(d) Select patient advocates for their ethnic/cultural diversity?              Yes            No

If yes, how long have you had this activity? ______(in years)

 

If no, do you have plans to undertake this activity?                               Yes            No

 

(e) Offer to communities educational programs that address health beliefs/needs of ethnic/cultural population?

 

If yes, how long have you had this activity? ______(in years)

 

Yes            No

If no, do you have plans to undertake this activity?                               Yes            No

 

Establish or contribute to community support groups for certain ethnic/cultural populations?

 

If yes, how long have you had this activity ?______(in years)

Yes            No

If no, do you have plans to undertake this activity?                               Yes            No

 

(g) Other

Yes            No

 

(please specify)

If yes, how long have you had this initiative? ______(in years)

If no, do you have plans to undertake such an initiative?                      Yes            No

 

43.       Has your healthcare organization established links with minority businesses for health promotion in the community?

 

Yes                        No (if no, skip to Q 45)

 

 

44.       How long have you had this link or program? ______(in years)

 

Skip to Q 46

45.       Do you have plans to undertake this activity? Yes   No

 

46.       Does your healthcare organization explicitly seek contract arrangements with ethnic/cultural businesses in your community?

 

Yes                        No (if no, skip to Q 49)

 

 

 

47.       If yes, please give examples.

 

 

 

 

48.       How long have you had this initiative or program? ______(in years)

 

Skip to Q 50

49.       Do you have plans  to undertake this activity? Yes  No

 

PART 3B:         ORGANIZATIONAL ADAPTATION TO DIVERSITY

 

50.       Do you have an organized way to collect data on the ethnic/cultural characteristics of patients (including patients who use community-based services)?

 

Yes                        No (if no, skip to Q 52)

 

51.       Is the database or information system used to identify the special needs of the ethnic/cultural patients in the following areas?

 

(a) Special meals

Yes

No

(b) Scheduling appointments

Yes

No

© Translation

Yes

No

(d) Other                                                    

Yes

No

(please specify)

 

52.       How does your healthcare organization determine the ethnic/cultural characteristics of the patients served?

 

 

53.       Do you survey patients to determine their perception of your services?

 

Yes                  No  (if no, skip to Q 59)

 

54. How often do you survey patients?

 

 

 

55.       Does your survey ask questions assessing service satisfaction related to cultural diversity?

 

Yes                  No  (if no, skip to Q 57)

56. How many questions addressing these issues are on the survey?                             _ Please attach copy of survey

 

57.       Is the survey available in languages other than English?

 

Yes                        No

 

58.       If yes to Q 57 above, in what languages is the survey available?

 

1.__________________        2.__________________         3.__________________

 

4._____________                   5.__________________         6.__________________

 

59.       In addressing the ethnic/cultural needs of patients throughout the continuum of their care,

do you provide the following, and if you do, how well do they work?

 

1                     2                      3                      4                      5

extremely                        somewhat                           not at all well

 

Use table for response.

 

 

Yes/No

If yes, how well do they work?

A. Appointment systems tailored for ethnic/cultural

populations in outpatient or specialty clinics

 

 

B. Protocols for addressing ethnic/cultural interpreting needs

 

 

C. Signs that direct patients to language/

cultural assistance

 

 

D. Accommodations for religious preferences of patients

 

 

E. Accommodations for the ethnic/cultural dietary preferences of patients

 

 

F. Assistance for ethnic/cultural populations in discharge planning

 

 

G. Other

 

 

 

 

(please specify)

 

 

60.       If yes to Q 59 C above, in what languages are the signs available?

 

1.___________                      2.__________________         3.__________________

 

4.__________________         5.__________________         6.__________________

 

If no to Q 59 C, skip to Q 62

 

61.       If yes to Q 59 C above, where are these directions posted?

 

(a) Emergency room                            Yes                  No

(b) Admissions                                    Yes                  No

(c) Outpatient clinics                           Yes                  No

(d) Other                                             Yes                  No

(please specify)

 

 

 

 

PART 3C: DATABASE SYSTEMS AND DATA DEVELOPMENT

 

62.       Does your healthcare organization maintain a computerized database documenting the characteristics of your ethnic/cultural staff? Database refers either to management information system (MIS) or human resources information system (HRIS).

 

Yes                        No (If no, skip to Q 67)

 

63.       Does your database or information system include the characteristics of ethnic/cultural staff; such as salary, rate of turnover, promotions, staff tenure, performance appraisals, training, absenteeism?

Circle yes if one or more of the above apply. Yes          No (if no, skip to Q 66)

 

64.       Is the database analyzed?

 

Yes                        No (if no, skip to Q 66)

 

 

65.       Describe the nature of analyses that apply to such data.

 

66.       Identify initiatives, programs or policies developed based on such analyses.

 

PART 3D:         LANGUAGE AND COMMUNICATION NEEDS OF PATIENTS AND STAFF

 

67.       Does your healthcare organization have written policies that relate to the provision of interpreter/translator services?

 

Yes                        No (if no, skip to Q 69)

 

68.       Please describe or attach these policy statements.

 

 

 

 

69.       Are hospital-based interpreter services required in your state or by any regulatory agency?

 

Yes                        No                   Don’t know

 

70.       Does your healthcare organization have interpreter/translator services?

 

Yes                        No (if no, skip to Q 85)

 

71.       Are your interpreter/translator services

 

(a) Hospital/Health System based?

Yes

No

(b) Non-hospital based?

Yes

No

 

If no to (a) and yes to (b), skip to Q 79

If no to (a) and no to (b), skip to Q 85

 

72.       If services are hospital based, is one specific office or department responsible for providing interpretation/translation services?

 

Yes                        No (if no, skip to Q 79)

 

73.       What is the name of the office or department?

 

 

 

 

74.       What are the principal duties of this office?

 

(a)_______________________________________________

 

(b)_______________________________________________

 

(c)_______________________________________________

 

75.       If your healthcare organization does not have a specific office dedicated to interpreter/translator services, please identify (a) the office or department; (b) the position title; and (c) how your healthcare organization addresses the language needs of patients and staff.

 

(a)                                                                                           

(b)                                                                                           

(c)                                                                                           

 

 

 

76.       In general, how effective are the hospital-based interpreter/translator services in addressing

the needs of your ethnic/cultural population?

 

1                      2                      3                      4                                5 extremely                                          somewhat                        not effective effective

 

77.       Does this office or your healthcare organization maintain a central registry documenting requests for interpreter/translator services?

 

Yes (if yes, skip to Q 79)              No

 

78.       How do you track or document the utilization of interpreter/translation services?

 

 

 

 

79.       What kind of non-hospital based interpreter/translator services does your healthcare

organization have?

 

(a) AT&T phone translation

Yes

No

(b) Friend or family

Yes

No

(c) Other                                       

Yes

No

(please specify)

 

 

 

80.       Does your system allocate support specifically for interpretation services?

 

Yes                        No (if no, skip to Q 85)

 

81.       What is the dollar amount of this support?

 

 

 

 

82.       Has the allocation changed over the past fiscal or calendar year?

 

Yes                        No (if no, skip to Q 85)

 

 

83.       What is the percent change in allocation. Indicate whether the change is positive (+) or negative (-).

 

 

 

84.       What percent of your interpreter/translator services is ‘paid, in contrast to voluntary?

STAFF ISSUES

85.       Does your healthcare organization have a policy for recruiting bilingual staff? Yes            No

 

86.       Does your healthcare organization give preference in hiring to bilingual staff?

 

Yes                        No

 

Text Box: (a) In the emergency room	Yes	No
(b) In ambulatory units	Yes	No
(c) On inpatient units	Yes	No
(d) At discharge	Yes	No
(e) On-call for off-shifts	Yes	No
87.       How or where are translators used? For Patients:

 

 

For Staff:

 

(f) Employment interviews

Yes

No

(g) Employee counseling

Yes

No

 

88.       Are interpreters trained in cross-cultural medical language?

 

Yes                        No (if no, skip to Q 91)

 

89.       How are the interpreters trained?

 

(a) In house training                Yes                  No

(b) Outside contractors           Yes                  No

 

90.       How effective is this training?

 

1                      2                      3                      4                      5 extremely                                    somewhat                                not effective effective

 

 

91.       Are interpreters and other staff trained to understand and respond to ethnic or cultural traditions (e.g. death/dying rituals, involvement of family, dietary preferences, etc.)?

 

Yes                        No (if no, skip to Q 94)

 

 

92.       Describe how interpreters and other staff are trained.

 

 

93.       How effective is this training?

1                      2                      3                      4                      5 extremely                                    somewhat                                not effective effective

 

94.       Does your healthcare organization assess the quality of interpretation services?

 

Yes                        No (if no, skip to Q 97)

 

95.       How does your healthcare organization assess the quality of these services?

 

 

96.       Does your healthcare organization test interpreters in their knowledge of medical

technology?

 

Yes                        No (if no, skip to Q 98)

 

97.       Are results used to make personnel decisions:

 

(a) Retrain an interpreter

Yes

No

(b) Evaluate interpreter performance

Yes

No

© Other________________

Yes

No

(please specify)

 

98.       Are interpreters accredited, or otherwise evaluated for proficiency?

 

Yes                        No

 

99.       Are medical staff and medical students given any training in communicating with ethnic/cultural minority patients?

 

Yes                        No (if no, skip to Q 102)

 

 

100.     Describe how medical staff and medical students are trained.

 

101.     How effective is this training?

 

1                      2                      3                      4                      5 extremely                                   somewhat                                not effective effective

 

 

PATIENT ISSUES

102.     Does your healthcare organization identify languages spoken in your service community? Yes    No

 

103.     How does your healthcare organization identify patients needing interpretation and translation?

 

(a) Identification by admissions assessment

Yes

No

(b) Identification by nursing assessment

Yes

No

(c) Identification by physician

Yes

No

(d) Medical support staff assessment

Yes

No

(e) Self-identification

Yes

No

(f) Other                                                                  

Yes

No

Text Box: Language	% of Staff
(please specify)

 

104.     What languages, other than English, are the principal languages of your patients and staff?

 

Language

% of Patients

 

 

 

 

 

 

 

 

 

 

 

 

 

105.     Estimate the percentage of patients served by your hospital who require interpreter

services:

 

106.     Does your healthcare organization measure patients satisfaction with your hospital’s interpreter/translator services?

 

Yes                        No

 

107.     Please indicate up to four (4) languages for which you have the highest demand for interpretation or translation.

 

Languages

Percent of all requests

 

 

 

 

 

 

 

 

 

 

108.     How does your healthcare organization acquire translated materials? Circ le all that apply

 

(a) Translated by hospital staff or person hired by contract               Yes                  No

(b) Translations by volunteers                                                             Yes                  No

(c) Translations purchased from professional translator                     Yes                  No

(d) Translated material secured from another hospital fa cility                       Yes

No

(e) Translated material secured from other (non-hospital)

agency or organization                                                                   Yes                  No

(f) Other                                                                                              Yes                  No

(please specify)

 

109.     What materials are translated into other languages?

 

For Patients:

 

(a) Patient education materials                                    Yes                  No

(b) Patient menu                                              Yes                  No

(c) Patient satisfaction survey                         Yes                  No

(d) Marketing/Advertisements                                    Yes                  No

(e) Billing information                                    Yes                  No

(f) Directions to sites/services                                     Yes                  No

(g) Patient directives (e.g. DNRs)

Yes

No

(h) Medication instructions

Yes

No

 

 

For Staff:

 

(a) Employee handbook

Yes

No

(b) Employee newsletters

Yes

No

(c) Employment application

Yes

No

 

110.     Does your healthcare organization have programs designed to address the needs of hearing or sight-impaired patients?

 

Yes                        No

 

If yes, please describe:                                                                                                           

 

 

 

111.     Does your healthcare organization provide interpreter services for the hearing or sight impaired patients?

 

Yes                        No

 

112.     Does your healthcare organization have special clinical or educational programs for gay/lesbian patients?

 

Yes                        No

 

If yes, please describe:                                                                                                           

 

 

 

 

113.     Does your healthcare organization have special clinical or education programs for the physically disabled?

 

Yes                        No

 

If yes, please describe:                                                                                                       

 

114.     Does your healthcare organization have special clinical or education programs for the mentally disabled?

 

Yes                        No

 

If yes, please describe:                                                                                                       

 

 

PART 3E:         BUSINESS       STRATEGIES   ATTRACTING   PATIENTS        FROM   DIVERSE CULTURES

 

115.     Are you undertaking special initiatives to target patients a nd expand services to ethnic/cultural populations in the following areas:

 

(a)  Marketing:

(a1) Advertising (e.g. newspapers, community fliers, churches, etc.)?           Yes      No

If yes, how long have you had this initiative?     ______(in years)

If no, do you have plans to undertake such an initiative?                       Yes      No

(a2) Recruitment drives in ethnic/cultural neighborhoods?                            Yes      No

If yes, how long have you had this initiative?      ______(in years)

If no, do you have plans to undertake such an initiative?                        Yes      No

 

(a3) Meetings with ethnic/cultural community organizations?                                   Yes

No

If yes, how long have you had this initiative?        ______(in years)

If no, do you have plans to undertake such an initiative?                        Yes      No

 

(a4) Meetings with ethnic/cultural business groups?                                      Yes      No

If yes, how long have you had this initiative?        ______(in years)

If no, do you have plans to undertake such an initiative?                         Yes      No

 

(a5) Other                                                                                             _         Yes      No

(please specify)

If yes, how long have you had this initiative?      ______(in years)

If no, do you have plans to undertake such an initiative?                        Yes      No

(b)  Services:

(b1) Developing services in ethnic/cultural communities?                              Yes      No

If yes, how long have you had this initiative?     ______(in years)

If no, do you have plans to undertake such an initiative?                       Yes      No

 

(b2) Expanding services in ethnic/cultural communities?                               Yes      No

If yes, how long have you had this initiative?     ______(in years)

If no, do you have plans to undertake such an initiative?                       Yes      No

 

(b3) Developing special ethnic/cultural related health programs, such as

hypertension education in Hispanic communities?                                  Yes      No

If yes, how long have you had this initiative?     ______(in years)

If no, do you have plans to undertake such an initiative?                       Yes      No

 

(b4) Monitor outcomes regarding ethnic/cultural minorities                           Yes      No

If yes, how long have you had this initiative?     ______(in years)

If no, do you have plans to undertake such an initiative?                       Yes      No

 

(b5) Other                                                                                                       Yes      No

(please specify)

If yes, how long have you had this initiative?      ______(in years)

If no, do you have plans to undertake such an initiative?                        Yes      No

 

116.     Do you have written policies for reviewing and assessing ethnic/cultural patient needs? Yes        No (if no, skip to Q 121)

 

117.     Please describe or attach these policies and procedures for reviewing and assessing ethnic/cultural patient needs; e.g. ombudsman, cross organizational team.

 

 

118.     Do these policies and procedures address all of your ethnic/cultural patient groups that have substantial numbers of patients? Yes (if yes, skip to Q 121)      No

 

119.     What groups are omitted?

 

 

1.__________________

2.__________________

3.__________________

 

 

4.__________________

 

5.__________________

 

6.__________________

 

120.

 

What groups are included?

 

 

 

 

1.__________________

 

2.________

 

3.__________________

 

 

4.__________________

 

5.__________________

 

6.__________________

 

121.     Has consideration of ethnic/cultural minority patient issues been incorporated into your healthcare organization’s Quality Improvement efforts?

Yes                        No

 

122.     Please describe how this has been done.

 

 



[2] Where the distinction between means and ends is not made, people ‘tend to get mired in endless all-talk-no-action circles that have disillusioned countless participants in past efforts’ (Friedman, 2000; p. 3)

 

 

[6] In practice this may not occur