Addressing Cultural
Competence with QI
November 9, 2007
Kathleen Clanon, MD, FACP
Hela Issaq, MPH
Patricia Calloway, RN
1
Funded by HRSA
HIV/AIDS Bureau
Questions for this Session
• Are the cultural challenges of HIV care a
problem, and is it our problem?
• Together with our patients, can we address
the problem and if so, how?
• What improvement ideas might work in our
clinics?
• How can we tell if the improvement ideas
were successful?
2
National Quality Center (NQC)
Disparities in Outcomes
In the United States, decline in HIV-related
mortality 1995-2001
• white men
85%
• black men
65%
• black women
50%
CDC AIDS/HIV Surveillance Report, Year End Edition 2001.
3
National Quality Center (NQC)
Is It an Access Issue?
• U.S. Military study. 129
soldiers starting HAART
1997-2003.

Blacks
After 12 Months:
AAs:
81 were African-American
% Undetectable
• All had coverage for M.D.
visits and meds.
• % BLQ on meds varied by
race at 12 months:


92% for whites
63% for AAs
% Dectectable
66%
Whites
Whites:
And at 24 months:


68% for whites
54% for AAs
% Undetectable
% Dectectable
92%
Hartzell J JAIDS; 44,4:April 1, 2007
4
National Quality Center (NQC)
1972 – The Tuskegee Syphilis Experiment
5
National Quality Center (NQC)
Patients with Linguistic Barriers
• Are less satisfied with care
• Make fewer visits and receive fewer
preventive svs
• Are less likely to use or return to clinics
• Score lower on health knowledge and
understanding of dx and rx
• Have longer hosp stays
Slide courtesy R. Like, MD
Fortier, J Bishop, D ‘Developing a Research Agenda for Cult. Comp. In Health Care,
Rockville, MD OMH and AHRQ, 2002
6
National Quality Center (NQC)
Cultural Competence Balancing Act
Improving Health Care Outcomes
Culture/Race Blind
7
Stereotyping,
Over-generalization,
Bias
National Quality Center (NQC)
Is It Our Problem?
Programs may decide to work on cultural competence
as a result of:
 patient complaints of different treatment based on race or
primary language.
 staff complaints of culturally-based conflict.
 concerns about demographic mismatches between staff
and clients.
 different rates of retention in care between groups.
Have you seen any red flags like this
in your program?
8
National Quality Center (NQC)
Disparities and Cultural Competence
• Are the cultural challenges of HIV care a
problem, and is it our problem?
• Together with our patients, can we
address the problem and if so, how?
• What improvement ideas might work in our
clinics?
• How can we tell if the improvement ideas
were successful?
9
National Quality Center (NQC)
Tackling the Tough Problems: Quality
as a Tool
Quality Improvement principles work with:
•
•
•
•
•
10
Systems not individuals
Problem-solving approach
Multidisciplinary teams
Steady, incremental change
No blaming
National Quality Center (NQC)
• Are the cultural challenges of HIV care a
problem, and is it our problem?
• Together with our patients, can we address
the problem and if so, how?
• What improvement ideas might work in
our clinics?
• How can we tell if the improvement ideas
were successful?
11
National Quality Center (NQC)
Step One: Examine the Evidence
Clinical quality data
Break it out by race and ethnicity; are there differences in success
rates for Paps, vaccinations, ARV prescribing or other clinical
quality measures?
Patient satisfaction survey results
Break it out by different racial and ethnic groups; are there
differences in satisfaction rates?
Do an organizational cultural competence assessment
Cultural Competence Health Practitioner Assessment (CCHPA)
http://www11.georgetown.edu/research/guccd/nccc/features/CCHPA.html
12
National Quality Center (NQC)
Collecting Race and Ethnicity Data
• Guessing is inaccurate, asking patients is
better, but guessing is what usually happens.
• Latino, Asian and multiracial patients
especially likely to be inaccurately identified if
not asked.
• Staff (and patients) uncomfortable about
asking, even if it is the policy to ask.
Hasnain-Wynia R. and D.W. Baker. Obtaining Data on Patient Race, Ethnicity, and
Primary Language in Health Care Organizations: Current Challenges and Proposed
Solutions. Health Services Research. August 2006; 41(4p1):1501-18.
13
National Quality Center (NQC)
Collecting Race and Ethnicity Data
• Train staff why race and ethnicity data are
important.
• Provide staff with script:
“We use this information to monitor care to
ensure that all patients get the best care
possible.”
Seigal B. Enhancing Public Hospitals’ Reporting of Data on Racial and Ethnic
Disparities in Care. The Commonwealth Fund. January 2007.
www.cmwf.org/publications.
14
National Quality Center (NQC)
Breaking Out the Data
Organizational Measures
Racial and Ethnic Comparison Between Staff and Patients
100
90
80
Percent
70
60
All Staff
50
Patients
40
30
20
10
0
White
15
Black
Latino
National Quality Center (NQC)
Breaking Out the Data
Clinical Quality Data
Percentage of Patients Who Had Two Visits in 2006
100
90
80
Percent
70
60
50
40
Black
Latino
White
Asian
30
20
10
0
16
National Quality Center (NQC)
Step Two: Make a Change
Case Study
AMC Clinic discovers that only 50% of their African American patients
are undetectable on ARVs, compared to 75% of their white patients.
The AMC Quality Committee takes on the issue. Their plan:
Concrete Aim: Improve the success rate of African American patients
on ARVs.
Measure:
Rate of African American patients undetectable on
ARVs increases to at least 75%.
Changes to test:
 Adherence counseling provided by peers instead of MD,
RN.
 Offer written materials for patients that are designed by
and for African American patients.
 Have a staff member ask patients if they have any
concerns about effects of ARVS in people of different
races.
17
National Quality Center (NQC)
Grantee Experience
Hela Issaq, MPH
QM Coordinator, Parts C and D, Oakland, CA
Patricia Calloway, RN
QM Coordinator, Part A, Oakland, CA
18
National Quality Center (NQC)
Questions Added to Consumer Survey
Oakland, CA
 I got services in the language I wanted*
 The staff asked about my health beliefs during my visits*
 The waiting room has materials that show people from my
racial or ethnic group*
 The staff at the clinic show respect for my religious beliefs*
*Answer choices for questions were:
All of the time, Most of the time, Sometimes, Rarely, Never, Doesn’t apply
19
National Quality Center (NQC)
Grantee Quality Improvement
• Chart reviews- better data collection of race,
ethnicity and primary language
• Contract language
• Cultural Competence Assessments- self and
agency
• Adding and/or improving language services
for limited English proficient clients
• Share the concept of Gracious Space
(shapes our interactions with others)
20
National Quality Center (NQC)
Choose Potential PDSA’s for Your Clinic
1. Look at exercise handout.
2. Choose 2 potential changes to test in your
clinic or practice.
Hints:
A. Choose from different categories.
B. Choose one long term and one short term project.
C. Choose something that staff and patients can get
excited about.
3. Volunteers report out to the group. Which of
these might you choose?
21
National Quality Center (NQC)
Step Three: Measure Progress
• Are the cultural challenges of HIV care a
problem, and is it our problem?
• Together with our patients, can we address
the problem and if so, how?
• What improvement ideas might work in our
clinics?
• How can we tell if the improvement ideas
were successful?
22
National Quality Center (NQC)
Step Three: Measure Progress
Look for narrowing of racial and ethnic gaps in:
 % of patients undetectable on ARVs, by race and
ethnicity
 % of patients receiving annual Gyn exam, by race
and ethnicity
 % of clients with broken appointments, by race
and ethnicity
23
National Quality Center (NQC)
General Cultural Competence Resources
• Cultural Competence Resources for Health Care
Providers
http://www.hrsa.gov/culturalcompetence
• Indicators of Cultural Competence in Health Care
Delivery Organizations: An Organizational Cultural
Competence Assessment Profile
http://www.hrsa.gov/culturalcompetence/indicators/
• AIDS Education and Training Centers, Guiding
Principles for Cultural Competency
http://www.aidsetc.org
24
National Quality Center (NQC)
National Quality Center (NQC)
www.NationalQualityCenter.org
Clanon: [email protected]
Issaq: [email protected]
Calloway: [email protected]
25
Funded by HRSA
HIV/AIDS Bureau
Extra Data Slides
26
Funded by HRSA
HIV/AIDS Bureau
Definitions
Cultural Competence:
“A set of congruent behaviors, attitudes, and policies
that come together in a system, agency, or among
professionals that enables effective work in crosscultural situations.”1
Health Disparities
“Racial or ethnic differences in the quality of
healthcare that are not due to access–related factors
or clinical needs, preferences, and appropriateness
of intervention.”2
1.
2.
27
HRSA’s Office of Minority Health
The Institute of Medicine
National Quality Center (NQC)
Perception of Racial Discrimination by the Health
Care System
Have you or a family
member or a friend been
treated unfairly because of
your race or ethnicity?
40
Concern that you or family
member will be treated
unfairly in the future
because of race or
ethnicity?
80
60
White
Black
Latino
20
0
YES
White
Black
Latino
40
20
0
Yes
NO
Kaiser Family Foundation Survey of Race, Ethnicity and Medical Care
1999.
28
National Quality Center (NQC)