Background
Method
Sampling strategy of approaches
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the approach was developed for wider than local use by a single health care organization;
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it was developed by an authoritative public body, such as a health ministry or a recognized group of experts;
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it was publicly available;
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the final selection included approaches from the US, Australia and Europe.
1. CLAS Standards - National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) [ 9 ]. These standards were developed by the Office of Minority Health, part of the U.S. Department of Health and Human Services. Some of the standards have the status of mandates, meaning that they are Federal requirements for all health care organizations that receive Federal funds; others are purely recommendations. We included the CLAS standards because they were the first one and probably the most comprehensive and influential approach currently in use. In May 2013 the Enhanced CLAS Standards were published [ 11 ]. Although largely similar, there are some differences of emphasis between the original and the Enhanced CLAS Standards: |
• The revised CLAS acknowledged that in order to address disparities in health care (for any target group), we need to go beyond cultural issues and deal with other (e.g., social, psychological) issues. |
• In the vision on responsive care some slight changes of emphasis could be found, such as a shift from regarding diversity as a ‘group’ characteristic to ‘appreciating the diversity of individuals’. The enhanced CLAS also places more emphasis on the importance of ‘patient- and family centred care’, thus bringing it more into line with the JC Roadmap. |
2. Advancing Effective Communication, Cultural Competence, and Patient- and Family Centered Care: A Roadmap for Hospitals (JCR) [ 20 ]. This ‘Roadmap’ has been developed by the Joint Commission (JC), an independent, not-for-profit organization which accredits and certifies health care organizations in the United States. The Roadmap was developed in addition to existing JC requirements “to inspire hospitals to integrate concepts from the fields of communication, cultural competence, and patient- and family-centered care into their organizations.” We included the JC Roadmap because of the global influence of JC and the Joint Commission International (JCI) accreditation program on health care organizations through their accreditation programs (applied in over 50 countries). JC developed its own framework of recommendations in which cultural competence is embedded within effective communication and patient- and family centred care. Please note that 1) other existing JC requirements also include issues related to those issues discussed in the Roadmap, and 2) that the national Joint Commission Standards are different from the Standards of the Joint Commission International. |
3. Cultural Responsiveness Framework. Guidelines for Victorian health services (CRF) by the Rural and Regional Health and Aged Care Services, Victorian Government, Department of Health (Australia) [ 21 ]. The CRF was developed to replace the Health Service Cultural Diversity Plans (HSCDPs) which since 2006 have required all Victorian health services to develop and implement policies for ethnic diversity in care. The intention of the CRF is to consolidate multiple requirements for reporting on cultural diversity initiatives within health services. All Victorian health services are required to submit plans and achievements according to the standards and measures in the CRF to the Statewide Quality Branch. We included the CRF because it has been disseminated and made compulsory in a large health care system in Australia. |
4. Recommendation of the committee of ministers to member states on mobility, migration and access to health care (COER) of the Council of Europe [ 22 , 23 ]. The Council of Europe is an international organization set up “to achieve a greater unity between its members for the purpose of safeguarding and realizing the ideals and principles which are their common heritage and facilitating their economic and social progress” [ 37 ]. We included the COER because it has been endorsed by the Health Ministers of the 47 member states of the Council of Europe. The document is aimed at ministerial level, therefore it includes recommendations that have consequences for the whole health system. These recommendations focus on the diversity responsiveness in the context of migrants and their children. To make comparisons possible we have only included the recommendations at organizational level in our analysis. |
5. Equality Delivery System (EDS) for the NHS [ 24 ]. EDS originates from the Equality and Diversity Council within the British National Health Service (NHS). It is designed to help NHS organizations to comply with the ‘Public Sector Equality Duty’ (PSED) of the Equality Act. This act “requires public bodies to consider all individuals when carrying out their day to day work – in shaping policy, in delivering services and in relation to their own employees” [ 38 ]. EDS is made available to the NHS as an optional tool. It was included because it is a European instrument which has been disseminated in a large health care system. |
6. Equity Standards (EQS) of the Task Force on Migrant-Friendly and Culturally Competent Healthcare [ 25 ]. These Standards were developed by a group of mainly European experts set up within WHO’s Health Promoting Hospitals network. The Equity Standards are a self-assessment instrument to enable health care organizations to carry out an ‘equity evaluation’ against a set of standards. The instrument was piloted in 10 European countries, as well as in two non-European ones. The Equity Standards were included because of the broad international context in which they were developed. |
Developing an analytical framework for the present analysis
Encoding of content
Comparison of content
Ethics statement
Results
Background information
Background information on model | CLAS Standards (CLAS) | Joint Commission Roadmap (JCR) | Cultural Responsiveness Framework (CRF) | Council of Europe Recommendations (COER) | Equality Delivery System (EDS) | Equity Standards (EQS) |
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origin
| US dept of Health and Human Services; Office of Minority health (U.S.) | The Joint Commission (U.S.) | Victorian Government; Dept. of Health (Australia) | Council of Europe; The committee of ministers (Europe) | The National Health Services (NHS); The Equality and Diversity Council (U.K.) | Health Promoting Hospitals; Task Force on Migrant-Friendly and Culturally Competent Health care (Europe) |
year
| 2001 | 2010 | 2009 | 2011 | 2011 | 2013 |
aim
| *ensure equitable and effective treatment in a culturally and linguistically appropriate manner *correct inequities *more responsive services *elimination of racial and ethnic health disparities *inform, guide and facilitate culturally and linguistically appropriate care | *improve overall safety and quality of care *integrate concepts from communication, cultural competence and patient-centered care fields into hospitals | *better links between access, equity, quality and safety *better health outcomes for culturally and linguistically diverse (CALD) populations *enhance cost effectiveness of service provision *track organizations' improvement; align cultural responsiveness (CR) with existing standards; develop benchmarks | *Equitable access to health care of appropriate quality | *better outcomes for patients and communities, better working environments for staff *improve equality performance *review equality performance *a tool to comply to the ‘public sector Equality Duty’. | *ensure equitable and accessible health care *reduce disparity in health care*an Equity self-assessment by health care organizations |
vision
| *cultural and linguistic competence *culturally and linguistically appropriate services (CLAS) | *effective communication (EC) *cultural competence (CC) *patient- and family-centered care (PFCC) | *cultural responsiveness (CR) | *improving the adaptation of health service provision to the needs, culture and social situation of migrants | *equality for patients and staff *personal, fair and diverse services and workplaces | *promoting equity |
target population
| *inclusive of all patients *especially racial, ethnic, and linguistic populations that experience unequal access | *no target group, recommendations address 'issues' in health care (e.g. language, culture etc.) | *Culturally and linguistically diverse populations (CALD) | *migrants | *protected groups | *migrants and all other vulnerable groups |
target organization-type
| *health care organizations *policymakers, accreditation agencies, purchasers, patients, advocates, educators, health care community in general | *hospitals | *all Victorian health services | *governments of CoE member states | *NHS commissioners and providers | *health care organizations |
structure
| *14 standards in three types: mandates (4), guidelines (9), and recommendations (1) *three themes: culturally competent care, language access services, and organizational supports for cultural competence | *54 recommendations structured around main points along the care continuum *aspects of the care continuum: admission; assessment; treatment; end of life care; discharge and transfer; organization readiness | *six standards across four domains, divided in measures and sub-measures (both quantitative and qualitative) *Standards: a whole organization approach; leadership; interpreters; inclusive practice; consumer/community involvement; staff. *Four domains: organizational effectiveness; risk management; consumer participation; effective workforce | *14 recommendations, specified in 31 sub-recommendations. | *18 outcomes grouped into four goals; nine steps for implementation *EDS goals: better health outcomes for all; improved patient access and experience; empowered, engaged, and well-supported staff; inclusive leadership at all levels | *five main standards, divided in substandards and measurable elements *main standards: equity in policy; equitable access and utilization; equitable quality of care; equity in participation; promoting equity |
‘Horizontal’ analysis (comparison of domain content across approaches)
Organizational commitment
Policy and leadership
Measuring and improving performance
Collecting data
Data on the population at large
Data on the patient population
Staff/Workforce
Staff competencies
Diversity in the workforce
Ensuring access
Entitlement to care
‘Understandable’ information
Geographical accessibility
Other aspects of accessibility
Care provision
Care responsive to needs and wishes
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CLAS and CRF focus on the cultural needs of patients, in accordance with their respective visions on responsive care (‘culturally competent’ and ‘culturally responsive’).
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JCR refers to ‘additional’ and ‘unique’ needs that should be integrated in the clinical process: “it is important for hospitals to be prepared to identify and address not just the clinical aspects of care, but also the spectrum of each patient’s demographic and personal characteristics”.
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COER focuses on the needs of migrants (broadly defined), going beyond cultural factors to consider social position, migration history and legal situation.
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EDS and EQS focus on needs resulting from patients’ individual characteristics.
Patient participation in the care process
Overcoming communication barriers in patient-provider contact
Understandable patient information materials
Trust
Patients’ rights
Patient and community participation at organizational level
Involving patients and communities in the development of services
Promoting responsiveness
Sharing information on experiences
Unique issues
‘Vertical’ analysis (comparing approaches)
DOMAINS & dimensions | ||||||
Organizational Commitment | CLAS | JCR | CRF | COER | EDS | EQS |
Policy and leadership | *a written strategic plan to provide culturally competent care *strategic plan is integrally tied to the organization's mission, principles, service focus | *demonstrate leadership commitment to effective communication (EC), cultural competence (CC), and patient- and family centered care (PFCC) *integrate concepts of EC, CC, PFCC into existing policies | *implement a Cultural Responsiveness (CR)-plan addressing the standards *integrate CR-plan into existing services’ plans and processes *demonstrate leadership *have an advising structure with participation of culturally and linguistically diverse (CALD) populations *allocation of financial resources *employ a cultural diversity staff member when CALD population > 20 % | *organization as a whole must be ‘culturally competent’ *implement the recommendations in a sustainable, coordinated and evidence based way | *leaders conduct and plan business so that equality is advanced *managers support and motivate staff to work culturally competent *recruit, develop and support strategic leaders to advance equality outcomes *integrate equality objectives into mainstream business planning | *a specific plan to promote equity, integrated with existing accountability systems *all organization plans promote equity |
Measuring and improving performance | *initial and on-going self-assessment of CLAS-related care *integrate CLAS-related measures into regular quality improvement programs (e.g. internal audits) *use data on individual patients for needs assessment, service planning and quality improvement | *a baseline assessment whether organization meets unique patient needs | *obligatory reporting on CR performance (on defined measures) *perform research in outcomes (e.g. emergency presentations) for CALD patients’ care needs *analyze quality/risk management data for CALD patients *report on CR performance in organization's regular performance reports *include CALD stakeholders in performance review | *evaluate existing services, identify existing problems, develop good practices *conduct research to identify problems, determine actions and evaluate interventions | *analyze performance, agree (with stakeholders) on results, and prepare equality objectives | *continually identify and monitor access and barriers in access, and evaluate interventions for reducing access barriers (e.g. communication support services) *use data on equity performance to improve equity in accessibility and quality |
Collecting data | CLAS | JCR | CRF | COER | EDS | EQS |
Data on the population at large | *maintain a current demographic, cultural and epidemiological profile, and a needs assessment of the community | *use available population-level demographic data of surrounding community | *monitor community profile and demographics | *governments (in partnership with other relevant organizations) collect background data and epidemiological data on migrants | *assemble evidence drawing on existing information systems (incl data on population level) | *collect or have access to data on health status and health inequalities of catchment area |
Data on the patient population | *collect data on individual patient's race, ethnicity, spoken/written language in health record *integrate CLAS-related measures into patient satisfaction assessments | *develop a system to collect patient-level data *collect data on patient race and ethnicity in medical record *collect data on patient's language and additional patient-level information (e.g. cultural, religious) *Collect feedback from patients, families | *develop appropriate information strategies for data collection, reporting and sharing *collect CALD patient satisfaction data | *assemble evidence including surveys of patient experiences | *organization's systems can measure equity performance *identify patients' needs according to characteristics (health records include information on demographic characteristics e.g. language, health literacy level, ethnicity) | |
Staff/workforce | CLAS | JCR | CRF | COER | EDS | EQS |
Staff competencies | *all staff receive on-going education in providing CLAS | *new and existing training addresses issues of EC, CC, PFCC | *provide staff at all levels with opportunities to enhance their CR *train staff *CR references included in HRM policies and practices (e.g. position description) *communication systems for sharing information on CR | *care professionals at various levels should be trained in accessibility issues and in cultural competence | *enable staff to be confident and provide appropriate care with support by training, personal development and performance appraisal | *all staff is aware and competent to address inequities due to education *specific training on equity issues *include equity issues in organization's core education |
Diversity in workforce | *strategies to recruit, retain and promote diverse staff, representative of demographic characteristics of service area *diverse staff at all levels, including diverse leadership | *recruitment efforts to increase a diverse workforce that reflects the patient population *diverse workforce can increase ethnic and language concordance, which may improve communication | *recruitment policies should ensure that the diversity of general population is reflected in the workforce (mentioned as an example) | *fair selection processes to increase diversity of all workforce *equality in levels of pay *staff can work in a safe environment (e.g. free from abuse, harassment etc.) *flexible working options | *fair and equitable workforce policies and practices *promote respect for dignity of all staff and volunteers | |
Ensuring access | CLAS | JCR | CRF | COER | EDS | EQS |
Entitlement to care | *legislation concerning entitlement is properly implemented *professionals at all levels are aware of eligibility rights | *monitor situations of people that are ineligible for care *ensure health care to people ineligible for services by providing appropriate support | ||||
‘Understandable' information | *patient related materials and post signage essential for access should be made easily understood *offer and provide language assistance services to all patients with LEP, at all contacts, in a timely manner during all hours of operation | *programs for migrants should include knowledge on health and illness, the way the health system works, and entitlements to health services *promote interpretation and translated materials to improve accessibility | *in communicating with people and providing information on access issues, health literacy and language needs are taken into account | |||
Geographical accessibility | *inconvenient locations should be reduced as far as possible | *minimize architectural, environmental and geographical barriers to facilities | ||||
Other aspects of accessibility | *remove accessibility barriers and reduce practical difficulties (e.g. inconvenient opening times) | *patients, carers and communities can readily access services *public health, vaccination and screening programs benefit all local communities/groups | *ensure access to care for disadvantaged people *provide outreach information to disadvantaged people on outreach services | |||
Care provision | CLAS | JCR | CRF | COER | EDS | EQS |
Care responsive to needs and wishes | *patients receive effective (positive outcomes), understandable and respectful (patients values taken into account) care *care should be compatible with cultural health beliefs and practices, and preferred languages | Throughout the care continuum: *ask for additional needs (e.g. cultural, religious) *communicate information about unique patient needs to relevant providers *start patient-provider interaction with an introduction *identify and accommodate cultural, religious, spiritual beliefs/practices that influence care *incorporate EC, CC, PFCC concepts into care delivery | *inclusive practice in care planning (including dietary, spiritual and other cultural practices) *implementation and revision of policies for provision of appropriate meals *use feedback/evaluation from patients to improve CR *develop and use suitable instruments for assessment (e.g. clinical diagnosis) which incorporate cultural considerations | *improve relevance and appropriateness of health services *offering the same services to everybody may result in users receiving lower quality of care *services should be culturally competent (matched to needs of migrants from diverse backgrounds) *culturally competent care goes beyond cultural factors, e.g. social position, history, legal situation should also be taken into account *adapt existing diagnostic and therapeutic procedures or invent new ones if necessary | *assess individual patients' health needs and provide appropriate and effective services *discuss changes across services with patients and make transitions smoothly *strive for positive treatment experiences: being listened to, being respected, privacy and dignity are prioritized | *In needs assessments, delivery of care and at discharge, patients’ individual, family characteristics, experiences and living conditions are taken into account (incl. psychosocial needs) *workforce is able to take into account individual patients' ideas and experiences of health and illness in clinical practice and at discharge *care is considerate and respectful of patients' dignity, personal values, knowledge and beliefs regarding health care |
Patient participation in the care process | *Involve patients, families, support persons in the care process along the care continuum. | *inclusive practice in care planning (including dietary, spiritual and other cultural practices) | *promote participation of migrants in all activities concerning the provision of health services, including decision making processes | *involve patients as they wish during the care continuum | ||
Overcoming communication barriers in patient-provider contact | *offer and provide language assistance services (including bilingual staff, interpreter services) at no costs to all patients with LEP, at all contacts, in a timely manner during all hours of operation *inform patients of their right to receive language assistance *assure competence of language assistance by interpreters and bilingual staff | *identify patient's preferred language or other communication needs during admission *identify and monitor patient communication needs/status during care continuum, document this in patient record *ensure competence of language assistance *develop a system to provide language services *inform patients of their rights for an interpreter | *implement language services policy *policies include directions about role of interpreters and family *provide accredited interpreters to patients who need one *match employment of in-house interpreters to community demographics *evaluate interpreter services | *high quality interpreting should be promoted *consider all available methods to reduce language barriers | *have a policy on overcoming language barriers *make professional interpreting services available and promote it *accommodate communication needs of patients with e.g. hearing, speech impairments *monitor quality of interpreting services/communication support *ensure staff ability to work with interpreter/communication support staff | |
‘Understandable’ patient information materials | *provide easily understood patient related materials (applications, consent forms) and post signage in diverse languages incl. directions to facility services (diverse language: languages of commonly encountered groups/groups represented in the service area) *take into account culture and health literacy levels *persons from small language groups have the right to oral translation | *provide patient education materials and instructions that meet patients' needs (health literacy, language) during assessment, treatment and discharge *support patient’s ability to understand/act on health information *determine needs for assistance with admission forms (health literacy) | *have appropriate translations of signage, patient forms, education materials for predominant language groups using services | *promote high quality translated written information | *provide easily understood written material and signage taking health literacy and language needs into account | |
Trust |
Conflict & grievance
*conflict/grievance procedures are culturally sensitive *conflict/grievance procedures can identify, prevent, resolve cross-cultural conflicts/complaints *staff handling complaints should receive cultural competence training *monitor culturally or linguistically related complaints Atmosphere *create a welcoming and inclusive environment |
Conflict & grievance
*accessible complaints system (language, non-writing) *complaints are not being subjected to coercion, discrimination, reprisal, or unreasonable interruption of care Atmosphere *create an environment that is inclusive of all patients *patient has the right to be free of neglect, exploitation and abuse (regular JC standards, chapter: Rights and Responsibilities of the Individual) |
Conflict & grievance
*monitor number of complaints lodged by CALD consumers/patients. |
Conflict & grievance
*complaints should be handled respectfully and efficiently Atmosphere *create a safe environment, without threat of dignity of denial of individual identity |
Atmosphere
*create a safe environment, with respect for patient's dignity and identity *create an environment inclusive for all patients | |
Patients’ rights | *provide notices in diverse language of a variety of patients’ rights (including right for language assistance) | *inform patients of their rights (interpreter, accommodation for disability, be free from discrimination, etc.) *tailor the informed consent process to meet patient needs (related to low HL) | *accommodate patients' diverse needs in informed consent procedure | |||
Patient and community participation at organizational level | CLAS | JCR | CRF | COER | EDS | EQS |
Involving patients and communities in the development of services | *utilize a variety mechanisms to facilitate community and patient involvement in designing and implementing services *develop participatory, collaborative partnerships with communities | *be involved and engaged with patients, families and the community to identify needs for new/modified services *collect feedback from patient, families and communities | *CALD consumer, carer and community members are involved in the planning, improvement and review of programs and services on an on-going basis *advice of participation structures is taken into account *facilitate different degrees of participation from CALD consumers, carers, community *develop partnerships with ethno-specific community organizations | *promote participation of migrants in designing, evaluating, and carrying out research on migrant health and health care *promote participation of migrants in developing and implementing new measures | *identify local interests (including patients, communities) that need to be involved in implementing EDS *share assembled information with local interests so they participate in analyzing performance and setting objectives *agree roles with local authority (e.g. services that share the same clientele) | *identify service users at risk for exclusion from participatory processes, promote their participation *identify and overcome barriers to participation *monitor and evaluate participatory processes *use feedback to improve services and share results of participation with public |
Promoting Responsiveness | CLAS | JCR | CRF | COER | EDS | EQS |
Sharing information on experiences | *make information available to public on progress and innovations in implementing CLAS *inform community, own organization (for institutionalizing CLAS) and other organizations to learn from each other | *share information with surrounding community about efforts to meet unique patients’ needs to demonstrate commitment | *undertake research to develop new and improved initiatives and resources for CR | *inform public adequately about issues concerning migrant health | *share assembled evidence on equality performance with local interests (e.g. patients, communities), so they can take part in analysing performance and set goals *publish accomplishments (grades) and equality objectives so they are accessible for local interests | *be a participant in networks, research initiatives which promote equity *disseminate results of research/practice related to equity *build solid relationships/ networks with community-based service providers *ensure that equity is reflected in all partnership and service contracts |
Unique issues | CLAS | JCR | CRF | COER | EDS | EQS |
*identify and address mobility needs (e.g. cane, guiding dogs) | *support workforce to remain healthy, focus on major health and lifestyle issues that affect individual and wider population |