A Summary of Awareness, Knowledge, Adoption, and Implementation of the A Summary of Awareness, Knowledge, Adoption, and Implementation of the National Standards for Culturally and National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Linguistically Appropriate Services (CLAS) in Health Careatat Healthand and Health Health Care Colorado Office of of Behavioral Health Colorado Office Behavioral Health August 2016
August 2016 Prepared for: Jane Flournoy, MA, LMFT, LPC, CAC III Colorado Office of Behavioral Health Culturally Informed & Inclusive Programs 3824 West Princeton Circle Denver, CO 80236
Prepared by: Health Determinants & Disparities Practice CSRA, Inc. 6003 Executive Boulevard Suite 400 Rockville, MD 20852
Acknowledgements This report was produced for the Colorado Office of Behavioral Health by the Health Determinants & Disparities Practice (HDDP) at CSRA, Inc., under contract number 263999900029I with the Office of Minority Health at the U.S. Department of Health and Human Services. The contributing authors were Jennifer Kenyon, Kimberly Green, and Crystal L. Barksdale of CSRA, Inc.; and Rodney Hopson and William Rodick of George Mason University. The views expressed in this report are those of the authors and do not necessarily represent those of the Office of Minority Health, U.S. Department of Health and Human Services. The Office of Minority Health at the U.S. Department of Health and Human Services is grateful for the Colorado Office of Behavioral Health’s participation in this evaluation project. The following report is being shared with you to provide a detailed snapshot of the Colorado Office of Behavioral Health’s CLAS-related activities and implementation of the National CLAS Standards.
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Table of Contents BACKGROUND ...................................................................................................................................................................................... 3 INTRODUCTION TO THE NATIONAL STANDARDS FOR CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES (CLAS) IN
HEALTH AND HEALTH CARE ................................................................................................................................................................................. 3 OVERVIEW OF THE NATIONAL CLAS STANDARDS EVALUATION PROJECT............................................................................................. 3 SUMMARY OF YOUR PARTICIPATION ......................................................................................................................................... 4 FINDINGS ................................................................................................................................................................................................ 5 YOUR ORGANIZATION’S AWARENESS OF THE NATIONAL CLAS STANDARDS ....................................................................................... 7 YOUR ORGANIZATION’S KNOWLEDGE OF THE NATIONAL CLAS STANDARDS ...................................................................................... 8 YOUR ORGANIZATION’S ADOPTION OF THE NATIONAL CLAS STANDARDS........................................................................................... 9 YOUR ORGANIZATION’S IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS ...........................................................................10 YOUR ORGANIZATION AND THE NATIONAL CLAS STANDARDS ................................................................................. 14 THEME 1: GOVERNANCE, LEADERSHIP, AND WORKFORCE .......................................................................................................................15 THEME 2: COMMUNICATION AND LANGUAGE ASSISTANCE ......................................................................................................................16 THEME 3: ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY ...............................................................................17 RECOMMENDATIONS ...................................................................................................................................................................... 19 CONCLUSION ...................................................................................................................................................................................... 24 APPENDIX A .......................................................................................................................................................................................... 25 THENATIONALSTANDARDSFORCULTURALLYAND LINGUISTICALLYAPPROPRIATE SERVICES IN HEALTH AND HEALTH CARE ..25 APPENDIX B ......................................................................................................................................................................................... 27 STAFF SURVEY DATA.............................................................................................................................................................................................27 APPENDIX C ......................................................................................................................................................................................... 32 LIST OF RESOURCES .............................................................................................................................................................................................32
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Background Introduction to the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care With the ever-changing demographic and health care landscape in the United States, health and health care organizations continue to recognize the need to provide equitable, effective, high quality care and services to all individuals they serve. Culturally and linguistically appropriate services (CLAS) are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs. CLAS is one way organizations can improve their provision of services to all individuals, regardless of race, ethnicity, language, socioeconomic status, and other cultural characteristics. The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health
Care (commonly referred to as the National CLAS Standards; see Appendix A), developed by the Office of Minority Health (OMH) at the U.S. Department of Health and Human Services (HHS), offers organizations such as yours a framework for delivering CLAS. Originally published in 2000 and revised in 2013, the Standards are intended to advance health equity, improve quality, and help eliminate health care disparities.
Overview of the National CLAS Standards Evaluation Project While the National CLAS Standards are increasingly recognized in health and health care as a tool for becoming more culturally and linguistically competent, they have not been systematically evaluated. Many health and health care organizations and professionals know little about the Standards, how to use them, and their intended outcomes. Therefore, OMH has sponsored an evaluation project to understand how health and health care organizations become aware of, gain knowledge about, decide to adopt, and ultimately implement the Standards. CSRA, Inc.’s Health Determinants & Disparities Practice (HDDP) and George Mason University’s Center for Education Policy and Evaluation, College of Education and Human Development have led and coordinated this project since its launch in 2014. The evaluation project consisted of two phases. Phase 1 involved interviews with CLAS and National CLAS
Standards’ stakeholders. Phase 2 involved leadership interviews, staff surveys, website reviews, and site visits with health and health care organizations across the United States. OMH is hopeful that these findings will help the field understand how health and health care organizations use the Standards. This understanding could inform policy recommendations and future organizational use of the Standards.
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Summary of Your Participation The Colorado Office of Behavioral Health’s (COBH) participation began in January 2016, when the Health Determinants & Disparities Practice contacted Ms. Jane Flournoy to invite your organization to participate in this project and then to coordinate data collection. Our team i n t e r v i e w e d 5 members of your leadership team, collected surveys from 11 of your staff and leadership, and reviewed your organization’s website. Fo r each data collection activity, we categorized our findings based on the ways the data reflected CLAS and the National CLAS Standards.
Leadership Interviews We completed telephone interviews, lasting approximately 90 minutes, with 5 members of leadership in your organization to understand their perspectives about how leaders at the Colorado Office of Behavioral Health became aware of, learned more about, decided to adopt, and currently use the National CLAS Standards.
Staff Surveys We distributed a brief web-based survey to select staff and leadership at the Colorado Office of Behavioral Health to describe the level of awareness and knowledge of the National
CLAS Standards, and to document staff’s observations and perspectives about how the organization adopted and implements the Standards. We received responses from 11 members of your staff and leadership. Per your report, 71 individuals received the invitation to complete the survey, yielding a response rate of approximately 15%. Of the 11 staff and leadership who completed the survey, most identified as female (82%; n=9); Caucasian (91%; n=10); and not of Hispanic, Latino, or Spanish origin (72%; n=8). Of those who completed the survey, about half (55%; n=6) reported their role as division manager/administrator. On average, those who completed the survey reported working 5 years at your organization. See Appendix B for full survey results.
Website Review We completed an independent, in-depth review of the Colorado Office of Behavioral Health’s website from the perspective of a person looking for more information on how the organization provides CLAS.
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Findings The evaluation project was organized by the concepts of Awareness, Knowledge, Adoption, and Implementation of the National CLAS Standards. In this report, you will find more information about these concepts, along with recommendations to use or reference when considering opportunities for improvement.
Evaluation Concepts Awareness
How organizations know the Standards exist
Knowledge
How organizations learn information about the Standards
Adoption
Whether and how organizations decide to use the Standards
Implementation
How organizations use the Standards
Though the project team has taken great care to collect comprehensive, informative data about CLAS and the
National CLAS Standards that can be of significant use to your organization, to OMH, and to the field, we would like to note the following important limitations to the data:
Given that your organization volunteered to participate in this project, the data received does not represent the larger population of health and health care organizations in the country. Your organization was selected to participate in this project because of your stated interest in participating and your demonstrated commitment to providing CLAS and implementing the Standards. The data presented reflects a sample of health and health care organizations that is supportive of CLAS and the Standards, which may introduce bias.
We worked closely with your organization’s point of contact to recruit members of your leadership and staff to participate in the various components of the project. The point of contact and his/her proxy selected members of your leadership to be interviewed and members of your staff and leadership to complete the survey based on criteria that we provided and the availability and willingness of these individuals to participate. We recognize that those who were selected to participate in the project may be more knowledgable and more supportive of CLAS and the Standards than those who were not selected and/or chose not to participate. This also introduces bias.
While this report describes staff and leaderships’ perceptions about implementing the Standards, we recognize that these responses are self-reported and thus subject to self-report bias. As such, we make no claim about the impact of implementing the Standards on clinical and non-clinical outcomes.
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Findings (cont’d) We have taken great care in interpreting and reporting the data collected, and we emphasize that the data reported is descriptive and should not be used to make conclusions about causation. In addition, although we extensively reviewed and cleaned the data collected, the accuracy of all the reported data cannot be guaranteed. Given these limitations, we urge the reader to exercise similar caution while reviewing these findings, and remember that the data gathered reflects the experiences of those individuals and organizations that participated in the evaluation project, and it canot be generalized to your organization as a whole or organizations that did not participate in the project.
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Findings (cont’d) Your Organization’s Awareness of the National CLAS Standards To understand the Colorado Office of Behavioral Health’s overall awareness of the Standards, we collected data to describe 1) the level of awareness of the Standards among leadership and staff, and 2) how staff became aware of the Standards.
Leadership Interviews The following is a summary of what we learned about staff and leadership awareness of the National CLAS Standards at COBH, according to members of your leadership. For your information, we have included data about awareness that we learned from leadership in the five other public health departments that participated in this evaluation.
The
Standards
are
generally
perceived
positively among staff at your organization, as they are at the other public health departments we studied.
The level of awareness at your organization varies among staff and leadership at your organization. We also found this to be true at the other public health departments.
Members of your leadership shared that staff members at your organization are aware of elements of the Standards but may not know about the Standards themselves.
Your organization and other public health departments noted that grants help to increase awareness of the Standards.
“I would say that there's been a lot of work done, especially at lower levels, to adhere, to really promote them…I think that there's more of a learning curve for leadership. Leadership, myself included; we typically have 100 really top high priority fire items in any given day. So, I think we have more work to do here in terms of leadership.” - COBH Leader
Staff Surveys The majority (73%; n=8) of the members of the staff and leadership who completed the survey indicated that they had heard of the
National CLAS Standards. Most of the staff and leadership who had heard of the Standards first learned about them from your organization (75%; n=6).
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73% had heard of the
Standards
Findings (cont’d)
Your Organization’s Knowledge of the National CLAS Standards To understand the Colorado Office of Behavioral Health’s overall knowledge of the National CLAS Standards, we collected data to describe 1) how members of your leadership describe the Standards, and 2) what your leadership and staff know about the Standards.
Leadership Interviews We asked members of your leadership to describe the National CLAS Standards. The following is an example of that description from our interviews, compared with how the Office of Minority Health describes the National CLAS Standards.
How your organization describes the
National CLAS Standards
How the Office of Minority Health describes the National CLAS
Standards
“I would really describe it as an allencompassing sort of standards of best practice when it comes to conducting our work in a way that's really culturally and linguistically inclusive and appropriate.”
The National CLAS Standards are 15 action steps that any health or health care entity can use to improve their services and communication, and are intended to advance health equity, improve quality, and help eliminate health care disparities.
Staff Surveys Of the 8 members of your staff and leadership completing the survey who indicated that they had heard of the National CLAS Standards:
About one-fourth (26%; n=6) felt moderately or very knowledgeable about the Standards.
Most reported knowing the purpose of the Standards (63%; n=5) and why the Standards should be used (75%; n=6).
About one-third (37%; n=3) indicated that your
26% felt moderately or very knowledgeable about the Standards
organization provides opportunities to learn about the Standards.
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Findings (cont’d) Your Organization’s Adoption of the National CLAS Standards To understand how the Colorado Office of Behavioral Health decided to use the National CLAS Standards, we collected data to describe 1) how your organization made the decision to use the Standards, 2) what factors made the decision easier or more difficult, and 3) if and how the decision to use the Standards was communicated within the organization.
Leadership Interviews We asked leaders at your organization about the process it took to decide to use the
National CLAS Standards. Below are findings learned from leadership at your organization and from leadership at other public health departments that participated in this evaluation.
At COBH and other public health departments, a dedicated staff member led the organization’s decision to adopt the Standards.
COBH and other public health departments found it easier to adopt the Standards because they are recognized as the “gold standard” for the field.
“…[W]e have a staff person who is designated – kind of our designated SME for culturally responsive treatment. So I would say that it's our staff who has trained us, often, with awareness. So they then
At other public health departments, the support of
adopted…we've been
leadership was identified as a critical component of
working with them at a
an organization’s decision to adopt the Standards. Other public health departments also reported holding an all-staff meeting or conference to communicate the decision to adopt the Standards.
Staff Surveys When asked whether the Colorado Office of Behavioral Health adopts the National CLAS
Standards, 82% (n=9) of staff and leadership who completed the survey replied “I don’t know.”
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lower level before it's kind of been formally adopted at a much higher level.” - COBH Leader
82% did not know whether your organization adopts the Standards
Findings (cont’d) Your Organization’s Implementation of the National CLAS Standards How organizations use the National CLAS Standards varies by organization and can include activities such as providing interpreter services for patients/clients, offering CLAS training for staff, or conducting an organizational assessment. To understand the ways in which the Colorado Office of Behavioral Health currently uses the National CLAS Standards, we collected data to describe how your organization implements the Standards.
Leadership Interviews According to members of your leadership, the Colorado Office of Behavioral Health implements the National CLAS Standards in the following ways:
Offering specialized trainings
Including CLAS language in contract, grant applications, and policy statements
Conducting organizational self-assessments
Developing and disseminating an annual report
Identifying a CLAS champion in your organization
In addition to the activities described by your leadership, leadership in other public health departments implement the Standards by providing language assistance services, collaborating with external organizations to support implementation, and providing compensation to the workforce to complete CLAS-related trainings. We wanted to know what factors made it easier for your organization and others to implement the Standards. Some of the factors described by your leadership include:
Access to resources related to CLAS and the Standards
Support from the Office of Minority Health
Identification of CLAS champions
A learning collaborative to help your organization implement the Standards. As one leader at your organization explained, “I love the model of the learning collaborative…having a learning collaborative kind of structure was really helpful. And then different people presented on the different standards, and we talked about how people implemented things in their agencies…That was a great learning experience that was so much more interactive than just having somebody stand up there and read the Standards.”
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Findings (cont’d) Leadership Interviews (cont’d) Leadership at other public health departments also mentioned that leadership support and organizational culture were helpful factors in their implementation of the Standards. On the other hand, we also wanted to understand what factors made implementation of the Standards difficult. Your leadership described the following difficulties:
Lack of concise, digestible resources on CLAS
Challenges in keeping CLAS as an organizational priority
Challenges in collecting meaningful data
To address similar difficulties faced, other public health departments that participated in this evaluation used strategies such as seeking and using publicly available resources, incentivizing implementation, and reinforcing the case for CLAS by emphasizing quality client care and customer service. Finally, we wanted to understand what happened in your organization as a result of implementing the
Standards. From your leadership’s perspective, your organization has observed:
Increased awareness of the Standards
Improved provision of language assistance services
“I think certainly when it comes to communication and language assistance, it's something that we as an organization…made it very well-known about the language line, and how – what we have available, so that we're able to communicate effectively. And within our crisis services statewide, we've certainly prioritized language assistance and interpretive services. So I think that's a shift that we've already seen.” - COBH Leader
At other public health departments that participated in this evaluation, additional changes that were observed by leadership because of implementing the Standards included:
Improved cultural and linguistic responsiveness to the populations served
Improved staff cultural and linguistic competency
Increased organizational capacity to provide services to more individuals
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Findings (cont’d) Staff Surveys
73%
The majority of staff and leadership who completed the survey (73%; n=8) indicated uncertainty about whether the Colorado Office of Behavioral Health implements the
National CLAS Standards.
did not know whether your organization implements the
Despite this, members of staff and leadership who
Standards
completed the survey reported observing specific practices that illustrate your organization’s implementation of the Standards, including that your organization:
Offers training on culturally and linguistically appropriate practices
Offers interpreters to those who need it, at no cost to the individual
Offers written materials in languages other than English
Collects demographic data from all who receive services
Involves community members in care/service planning
Because fewer than 5 of those completing the survey reported that your organization implements the National CLAS Standards, we have not included additional survey findings about changes observed by staff following the implementation of the Standards.
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Findings (cont’d) Website Review We also completed a review of the Colorado Office of Behavioral Health website. The website was fairly simple and easy to navigate. It was clear from the website that your organization values cultural and linguistic competency and that your work is closely tied to the National CLAS Standards. The following are a few highlights related to implementation from the website review.
The Human Resources Division published the FY 2014-2015 State of Colorado Workforce Report, which includes demographic statistics on the workforce. No demographic statistics were found on the governance or leadership.
The Culturally Informed and Inclusive Behavioral Health webpage for your workforce provided information on two committees that are focused on culturally informed and inclusive behavioral health.
The 2015 Behavioral Health Equity Report and the Colorado Department of Human Services Office of Behavioral Health Needs Analysis were easily accessible from the Publications webpage. Both reports referenced health statistics by race/ethnicity, gender, and age and detail strategies to better provide for behavioral health needs in the service area. The Behavioral Health Equity Report specifically described the importance of a culturally and linguistically diverse workforce by highlighting “Workforce Development and Training” as one of the major themes of the report.
The website did not highlight the availability of communication and language assistance services.
Few translated materials were found on the website besides an Infectious Disease Screening Instrument and the Patients’ Bill of Rights, both of which were found in Spanish.
A link was found to translate the website into several different languages using Google Translate.
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Your Organization and the National CLAS Standards The previous section presents our findings by data source. However, we think it is also helpful to look at your implementation practices holistically to identify overall areas of success and opportunities for improvement. The following sections summarize your organization’s implementation practices by the three Themes of the
National CLAS Standards. Each table notes common implementation practices, degree of evidence of the practice we observed at your organization, and the data source. The Evidence Observed column organizes our findings by significant evidence observed, sufficient evidence observed, and little evidence observed. Significant refers to implementation practices where evidence was found in each data source collected. Sufficient refers to implementation practices where evidence was found in at least one, but not all, data sources collected. Little refers to implementation practices where evidence was not found in any of the data sources collected.
Implementation Practices Key Significant Evidence was found in each data source collected
Sufficient
Evidence was found in at least one, but not all, data sources collected
Little
Evidence was not found in any of the data sources collected
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Your Organization and the National CLAS Standards (cont’d) Theme 1: Governance, Leadership, and Workforce The Governance, Leadership, and Workforce Theme emphasizes that implementing CLAS is the responsibility of the entire health system, requiring the investment, support, and training of all individuals within an organization. There was sufficient evidence that your organization’s governance and leadership promote CLAS in policies and practices as well as provide CLAS-related trainings for the workforce. For example, as noted in the leadership interview summary, one leader at your organization mentioned that language on CLAS and the Standards is included in policy statements. The team also found sufficient evidence that your organization provides CLAS-related trainings to staff. About one-half (55%; n=6) of the staff and leadership that completed the survey reported that your organization offers training on culturally and linguistically appropriate practices. We observed little evidence that your organization actively recruits and promotes a diverse workforce, though the 2015 Behavioral Health Equity Report states that workforce diversity is a particular challenge for your organization. Evidence Observed Evidence Observed Theme 1 Implementation Practices
at Other Public
at Your
Health
Organization
Departments in the
Data Source(s)
Evaluation Project Governance and leadership promote
Sufficient
Significant
CLAS in policies and practices Organization actively recruits, supports, and promotes diverse
Leadership interviews Website review
Little
Sufficient
Little
Sufficient
Sufficient
Significant
individuals for leadership and non-
N/A
leadership positions Governance, leadership, and workforce is representative of
N/A
diversity of the community you serve Organization offers training on culturally and linguistically
Staff survey Website review
appropriate practices and policies
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Your Organization and the National CLAS Standards (cont’d) Theme 2: Communication and Language Assistance The Communication and Language Assistance theme covers all communication needs and services, including sign language, braille, oral interpretation, and written translation. There was sufficient evidence that your organization offers communication and language assistance services. About three-quarters (73%; n=8) of the staff and leadership that completed the survey reported that your organization offers interpreters at no cost to the individual. One leader at your organization also noted that providing interpreter services has been a significant priority for your organization, especially for crisis services statewide. However, the website review provided little evidence of Theme 2 implementation practices. As noted in the website review summary, the reviewers found few translated materials on the website besides an Infectious Disease Screening Instrument and the Patients’ Bill of Rights in Spanish. Evidence Observed Theme 2 Implementation Practices
Evidence Observed
at Other Public
at Your
Health
Organization
Departments in the
Data Source(s)
Evaluation Project Organization offers communication and language assistance services to
Sufficient
Sufficient
Staff survey
individuals at no cost to them Organization informs all individuals of the availability of language
Sufficient
Sufficient
competence of individuals providing
Leadership interviews Staff survey
assistance services Organization ensures the
Leadership interviews
Little
Little
Sufficient
Sufficient
N/A
language assistance Organization provides materials written in languages other than English
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Staff surveys
Your Organization and the National CLAS Standards (cont’d) Theme 3: Engagement, Continuous Improvement, and Accountability The Engagement, Continuous Improvement, and Accountability theme focuses on the supports necessary for adoption, implementation, and maintenance of CLAS. Effective delivery of CLAS requires action across an organization. The team found sufficient evidence from the website review and leadership interviews that your organization conducts regular organizational assessments and community health needs assessments. For example, the Colorado Department of Human Services Office of Behavioral Health Needs Analysis found in the website review provided demographic statistics and strategies for better serving the needs of the service area. We observed little evidence that your organization offers a way for individuals to provide feedback on care/services. There was also little evidence that the mission and vision of Colorado Office of Behavioral Health includes CLAS-specific goals. Evidence Observed Evidence Observed Theme 3 Implementation Practices
at Other Public
at Your
Health
Organization
Departments in the
Data Source(s)
Evaluation Project Organization’s mission/vision statement includes culturally and
Little
Little
Sufficient
Sufficient
Sufficient
Sufficient
Sufficient
Sufficient
Sufficient
Sufficient
N/A
linguistically appropriate goals Organization conducts ongoing organizational assessments of CLAS-
Leadership interviews
related activities Organization collects demographic data from all who receive
Staff surveys Website review
care/services Organization conducts regular community health needs
Website review
assessments Organization partners with the community to ensure cultural and linguistic appropriateness of services
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Staff survey
Your Organization and the National CLAS Standards (cont’d)
Theme 3 Implementation Practices (cont’d)
Evidence Observed at Your Organization
Evidence Observed at Other Public
Data Source(s)
Health Departments in the Evaluation Project
Organization offers ways for individuals to provide feedback on
Little
Little
Sufficient
Sufficient
N/A
care/services Organization informs people internally or externally about how
Leadership Interviews Website Review
CLAS is being provided
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Recommendations We provide the following recommendations to help the Colorado Office of Behavioral Health advance its implementation of the National CLAS Standards. In the tables below, we have listed the implementation practices where we found Sufficient or Little evidence. These recommendations have been developed based on interviews with CLAS and National CLAS Standards experts, the literature, and OMH’s implementation guide for the Standards, called The Blueprint. Theme 1 Implementation Practice
Recommendations
Incorporate CLAS into mission, vision, and/or strategic plans by determining how the organization acknowledges and addresses concepts such as diversity, equity, inclusion, and practices such as asking about preferences for care/services. Revise mission, vision, and/or strategic plans, as necessary, to include references to how
Governance and leadership promote
these issues are or will be addressed and monitored.
CLAS in policies and practices
Ensure members of the organization's leadership are informed of and involved in the implementation process by requiring their active participation in regular meetings and/or in conversations about CLAS and the Standards, which can facilitate their promotion of CLAS activities.
Collaborate with universities and colleges, especially Historically
Organization actively recruits,
Black Colleges and Universities (HBCUs), Historically Hispanic
supports, and promotes diverse
Colleges, and Tribal Colleges and Universities, to recruit for leadership
individuals for leadership and non-
and non-leadership positions through actions such as participating in
leadership positions
job fairs at these institutions and/or working with alumni networks to feature your organization and the opportunities available.
Target recruitment efforts to the communities and populations served to increase the recruitment of culturally and linguistically diverse individuals by actions such as posting job descriptions in in
Governance, leadership, and workforce is representative of diversity of the community you serve
multiple languages in local community media (e.g., local foreign language newspapers, social media groups, community blogs), holding job fairs in the community(ies) served (in schools, libraries, places of worship, etc.), and/or working with leaders of local community institutions (e.g., schools, churches/places of worship, libraries) to create mentorship and training programs targeting populations served for open positions (e.g., pipeline programs).
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Recommendations (cont’d) Theme 1 (cont’d) Implementation Practice
Recommendations
Invite members of the community(ies) served to help improve workforce training through actions such as inviting leaders/gatekeepers of the community(ies) served (e.g., school principals, religious leaders) to give presentations on relevant topics to the workforce, creating opportunities for individuals in community(ies) served and workforce to co-learn through cosponsoring health fairs, health education opportunities (e.g., CPR classes, nutrition classes), and other health events with local community institutions (e.g., schools, libraries, places of worship).
Organization offers training on culturally and linguistically
appropriate practices and policies
Disseminate existing CLAS-related resources (e.g., written information, publications, other literature, webinars) within the organization using widely accessible platforms (e.g., employeededicated webpages, employee Intranet, employee lunch/break room).
Create and disseminate new resources (e.g., information, written material, publications, other literature, webinars) about the CLAS and the Standards within the organization using widely accessible platforms (e.g., employee-dedicated webpages, employee Intranet, employee lunch/break room) within the organization.
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Recommendations (cont’d) Theme 2 Implementation Practice
Recommendations
Complete an organizational assessment specific to language
Organization offers communication
assistance services to describe existing language assistance services,
and language assistance services to
and to determine how existing services can be used more effectively
individuals at no cost to them
and efficiently to provide language assistance services to individuals
Organizations should provide notification that describes what communication and language assistance is available, in what languages the assistance is available, and to whom they are available. Notification should clearly state that communication and
Organization informs all individuals of
language assistance is provided by the organization free of charge to
the availability of language
individuals. It is recommended that organizations standardize
assistance services
procedures for staff members who serve as the initial point of contact for individuals, whether that is by telephone or in person, and it may be appropriate to provide staff with a script to ensure that they inform individuals of the availability of language assistance and to inquire whether they will need to utilize any of the available services.
Require that all individuals serving as interpreters complete certification and other formal assessments of linguistic and health care terminology skills to demonstrate competency to provide
Organization ensures the
interpretation services in organization.
competence of individuals providing language assistance
Provide financial and human resource (e.g., time off) incentives to staff/workforce that complete interpreter training and meet assessment criteria, to build organizational capacity to provide competent language assistance.
Organization provides materials
Formalize processes for translating materials into languages other
written in languages other than
than English and for evaluating the quality of these translations. This
English
may include testing materials with target audiences.
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Recommendations (cont’d) Theme 3 Implementation Practice
Recommendations •
Incorporate CLAS into mission, vision, and/or strategic plans by determining
Organization’s mission/vision
how
organization
acknowledges
and
addresses
concepts such as diversity, equity, inclusion, and practices such as
statement includes culturally and
asking about preferences for care/services. Revise mission, vision,
linguistically appropriate goals
and/or strategic plans, as necessary, to include references to how these issues are or will be addressed and monitored
Complete CLAS-related organizational assessment of the cultural and linguistic needs of populations served and of organizational resources to address these needs using internally-created or externally available organizational assessments (See resources in Appendix C).
Organization conducts ongoing organizational assessments of CLASrelated activities
Tailor existing evaluation efforts to include measures of NCS implementation (e.g., patient/client satisfaction measures can be modified to include questions about receiving culturally and linguistically appropriate care; outcome data can be stratified by REaL data to determine demographic differences and highlight areas of need).
At a minimum, collect race, ethnicity, and language (REaL) data from all individuals receiving care/services, either by using and tailoring (if necessary) existing data collection approaches, or creating
Organization collects demographic
a new data collection process.
data from all who receive care/services
Use REaL data to identify needs, to describe current care and service provision trends, and to improve care and service provision to culturally and linguistically diverse groups.
Organization conducts regular community health needs assessments
Collaborate with other organizations and stakeholders in data collection, analysis, and reporting efforts to increase data reliability and validity, and conduct focus groups with individuals in the community.
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Recommendations (cont’d) Theme 3 (cont’d) Implementation Practice
Recommendations
Include members of the community(ies) served in the process of planning programs and developing policies through actions such as:
Organization partners with the
convening town hall meetings, convening focus groups to solicit
community to ensure cultural and
community members’ feedback about services or programs offered,
linguistic appropriateness of services
and/or creating community advisory groups programs offered, and/or creating community advisory groups
Organization offers ways for
Consider using staff as cultural brokers to help improve feedback
individuals to provide feedback on
mechanisms and communication with culturally and linguistically
care/services
diverse individuals.
Draft and distribute materials that demonstrate efforts to be culturally and linguistically responsive. Partner with community organizations to lead discussions about the services provided and
Organization informs people
progress made, and create advisory boards on issues affecting
internally or externally about how
diverse populations and how best to serve and reach them. Convene
CLAS is being provided
educational forums where community partners and representatives can assess and evaluate the validity and application of recommendations, resources, and materials to their communities’ cultural, social, and economic circumstances.
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Conclusion We would like to thank you again for your participation in the evaluation project. The data that your organization has provided and shared with us is invaluable as we try to learn more about how health and health care organizations become aware of, learn more about, decide to use, and ultimately implement the
National CLAS Standards. We were very excited to learn about the amount of work the Colorado Office of Behavioral Health is doing to provide culturally and linguistically appropriate services and implement the National CLAS Standards. The way in which your organization provides trainings on CLAS-related policies and practices is especially notable. This is especially evident from the staff surveys, which indicated that the majority of staff who were aware of the Standards heard about the Standards from your organization. The amount of CLAS-related reports available online also speaks to the level of effort your organization is making to promote CLAS and eliminate health care disparities. We hope this report and the recommendations included are useful as you continue to advance your CLAS and National CLAS Standards implementation efforts. We also hope that you consider opportunities for improvement and celebrate the areas of success as you provide the best services possible to every individual you serve. Please see Appendix C for additional recommended resources. We invite you to use the Think Cultural Health website and the Office of Minority Health as a trusted resource to support your work to provide equitable, effective, high quality health care and services. If you have any further questions, please contact the Health Determinants & Disparities Practice at
[email protected].
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Appendix A The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations to: Principal Standard: 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: 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: 5.
Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate 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.
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Appendix A (cont’d) The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (cont’d) Engagement, Continuous Improvement, and Accountability: 9.
Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.
10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLASrelated measures into measurement and continuous quality improvement activities. 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. 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. 13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. 15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public
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Appendix B Staff Survey Data Table 1. Demographic Characteristics of Survey Respondents N=11 n (%) Gender
Female
9 (82)
Male
2 (18)
Race
White/Caucasian
10 (91)
Other
1 (9)
Ethnicity
Not Hispanic, Latino, or Spanish Origin
8 (72)
Another Hispanic
1 (9)
Mexican
1 (9)
Primary Work Role
Division/Sector Manager or Administrator
6 (55)
Division/Sector Supervisor
2 (18)
Other
3 (27)
Average Number of Years in Organization
4.91
Average Number of Years in Current Position
3.55
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Appendix B (cont’d) Staff Survey Data (cont’d) Table 2. Characteristics of Awareness, Knowledge, Adoption, and Implementation of the National CLAS Standards N=11 n (%) Awareness and Knowledge of the National CLAS Standards Have You Heard of the National CLAS Standards? No
3 (27)
Yes
8 (73)
How Did you First Learn about the National CLAS Standards?* (N=8)
Current Employer
6 (75)
Past Employer
1 (13)
Professional Development
0 (0)
Website
0 (0)
Other
1 (13)
How Knowledgeable are you about the National CLAS Standards? (N=8) Not At All
0 (0)
A Little
6 (75)
Moderately
1 (13)
Very Much
1 (13)
Which of the Following Do You Know about the National CLAS
Standards?* (N=8) Know Number of Standards
1 (13)
Know Number of Themes
1 (13)
Know the Purpose of Standards
5 (63)
Know Why the Standards Should be Used
6 (75)
None
0 (0)
*Categories are not mutually exclusive, so total may exceed 100%
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Appendix B (cont’d) Staff Survey Data (cont’d) Table 2. Characteristics of Awareness, Knowledge, Adoption, and Implementation of the National CLAS Standards (cont’d) N=11 n (%) Does Your Organization Provide Opportunities to Learn about the
National CLAS Standards? (N=8) No
1 (13)
Yes
3 (37)
I Don’t Know
4 (50) Adoption of the National CLAS Standards
Does Your Organization Adopt the National CLAS Standards? No
2 (18)
Yes
0 (0)
I Don’t Know
9 (82) Implementation of the National CLAS Standards
Does Your Organization Implement the National CLAS Standards? No
2 (18)
Yes
1 (9)
I Don’t Know
8 (73)
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Appendix B (cont’d) Staff Survey Data (cont’d) Percentage of Respondents who Observed Theme 1 Implementation Practices Trains on CLA practices
55
Recruits diverse people - non-leadership positions
45
Workforce is representative of community
45
Trains on CLA policies
36
Governance/leadership promotes CLAS
36
Recruits diverse people - leadership positions
27
Governance/leadership is representative of community
18 0
10
20
30
40
50
60
70
80
90
100 n=11
Percentage of Respondents who Observed Theme 2 Implementation Practices Offers Interpreters at no cost
73
Offers materials in other languages
64
Informs of availability of interpreter services
64
Communication assistance services offered at no cost
36
Has written policy/procedure for interpreters
27
Uses signs in languages other than English
9 0
10
20
30
40
50
60
70
80
90
100 n=11
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Appendix B (cont’d) Staff Survey Data (cont’d) Percentage of Respondents who Observed Theme 3 Implementation Practices Collects demographic data
73
Involves community in service planning
64
Mission/vision includes CLA goals
45
Informs about CLAS internally
36
Collects health needs data
36
Informs about CLAS externally
27
Offers way for people to provide feedback
18
Conducts regular assessments of CLAS
9 0
10
20
30
40
50
60
70
80
90
100 n=11
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Appendix C List of Resources General
A Blueprint for Advancing and Sustaining CLAS Policy and Practice – Office of Minority Health, U.S. Department of Health and Human Services
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals – The Joint Commission
Cultural Competency Assessment Tool for Hospitals – Office of Minority Health, U.S. Department of Health and Human Services; The Commonwealth Fund
Cultural Competency Resource Guide – Southeastern Health Equity Council, National Partnership for Action to End Health Disparities, U.S. Department of Health and Human Services
Taking Cultural Competency from Theory to Action – California Pan-Ethnic Health Network; The Commonwealth Fund
Theme 1: Governance, Leadership, and Workforce
Building a Culturally Competent Organization: The Quest for Equity in Health Care – Health Research & Educational Trust, Institute for Diversity in Health Management
In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce – Institute of Medicine
Strategies for Leadership: Does Your Hospital Reflect the Community It Serves? Diversity and Cultural Proficiency Assessment Tool for Leaders – Institute for Diversity in Health Management
Theme 2: Communication and Language Assistance
Guidance to Federal Financial Assistance Recipients Regarding Title VI and the Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons – Office for Civil Rights, U.S. Department of Health and Human Services
Guide to Providing Effective Communication and Language Assistance Services – Office of Minority Health, U.S. Department of Health and Human Services
Health Literacy Universal Precautions Toolkit – Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services
Limited English Proficiency – A Federal Interagency Website
Toolkit for Making Written Material Clear and Effective – Centers for Medicare & Medicare Services, U.S. Department of Health and Human Services 32
Appendix C (cont’d) List of Resources (cont’d) Theme 3: Engagement, Continuous Improvement, and Accountability
Bridging the Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker Programs – National Center for Cultural Competence
Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cultural Competence Item Set – Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services
Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Literacy Item Set – Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services
Communication Climate Assessment Toolkit – University of Colorado Center for Bioethics and Humanities
Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status – U.S. Department of Health and Human Services
Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile – Healthcare Research and Services Administration, U.S. Department of Health and Human Services
One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations – The Joint Commission
Principles of Community Engagement – U.S. Department of Health and Human Services
Self-Assessment Tools and Documents – National Center for Cultural Competence
The Collaboration Primer: Proven Strategies, Considerations, and Tools to Get You Started – Health Research & Educational Trust
Toolkit for Assessing Community Needs and Resources – The Community Tool Box, University of Kansas
Toolkit for Creating and Maintaining Partnerships – The Community Tool Box, University of Kansas
Toolkit for Enhancing Cultural Competence – The Community Tool Box, University of Kansas
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