Cultural Competence as a Quality Issue:
Practical Next Steps to Improvement
Technical Assistance Call
11/12/08
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Funded by HRSA
HIV/AIDS Bureau
Road Map for the Call
• Faculty Introductions
• Getting cultural competence
on the quality agenda
• Making progress using the
Model for Improvement
 Faculty real world experiences
 Tips and ideas
 Resources for more research
• And your Q and A and
comments throughout the
call.
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National Quality Center (NQC)
Faculty Introductions
• Kathleen Clanon, MD [email protected]
NQC Consultant
• Nancy Koughan, D.O., M.P.H. [email protected]
Lead Physician, Early Care Clinic, DeKalb County Board of Health, GA
• Daniel Barba, JD [email protected]
Program Manager, Family Care Network, Oakland
• Patricia Calloway, RN [email protected]
QM Coordinator, Part A, Oakland CA
• Hela Issaq, MPH [email protected]
QM Coordinator, Part C and D, Oakland (ret.)
• Nancy Halloran, MSW [email protected]
Program Planner Part C and D, Oakland
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National Quality Center (NQC)
Name Confusion
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Cultural Compentence
Cultural Competency
Cultural Humility
Cultural Fluency
Culturally Affirmative Practice
Cultural Proficiency
National Quality Center (NQC)
HRSA Uses: “Cultural Competence”
“Cultural competence is a set of attitudes, skills, behaviors, and policies
that enable organizations and staff to work effectively in cross-cultural
situations.”
HRSA Care Action Bulletin 2002
Cross et. al. 1989 and Lavizzo-Mourney and Mackenzie 1996 as cited in Cultural Competence: A Journey, Bureau of Primary Health
Care. Health Resources and Services Administration, US Department of Health and Human Services, n.d.)
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National Quality Center (NQC)
Using QI to Improve Cultural Competence
• Step One: Getting Cultural Competence on
the quality agenda.
We know it’s a problem, but is it our
problem?
• Step Two: Deciding on an Aim
What are we trying to accomplish?
• Step Three: Defining Measures
How Will We Know a Change is An
Improvement?
• Step Four: Planning and Testing Changes
What change can we make that will result in
improvement?
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National Quality Center (NQC)
Step One: Getting Cultural
Competence on the Quality Agenda
Panel Question: What made
your organization decide
that you needed to work on
cultural competence?
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National Quality Center (NQC)
What might make organizations put cultural
competence on the Quality Agenda?
 National data showing disparities in care and
outcomes.
 Local complaints or concerns
 Formal baseline assessment of your organization’s
cultural competence
 Federal requirements: National Standards for
Culturally and Linguistically Appropriate
Services (CLAS Standards)
www.omhrc.gov/assets/pdf/checked/finalreport.pdf
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National Quality Center (NQC)
National Data: Disparities in Care
 Entry into Care:
 African-Americans and Latinos are likely to be
diagnosed at a later disease stage than whites1
 Starting Treatment:
 African-Americans in one large national sample
study were 59% less likely than whites to be
receiving HAART2
 Success with Treatment:
 63% of African-Americans had an undetectable viral
load after one year of treatment vs 92% of whites.
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See references on end slide
National Quality Center (NQC)
Local Complaints and Concerns
 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
in your program?
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National Quality Center (NQC)
Formal Baseline Assessments of Cultural
Competence
• Organizational Self-Assessment
 Knowing the community you serve
 Ability to collect data on race, ethnicity and primary
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language
Hiring and training policies
Translation and interpretation services
Assessing and addressing health beliefs
(http://www.aidsetc.org/doc/workgroups/cc-questionbank.doc)
• Patient Input
 Survey, focus groups, CABs
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National Quality Center (NQC)
Example: Patient Satisfaction Survey
Cultural Competence Questions
In the 2008 client satisfaction survey in Oakland, these
questions were included:
 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.
 I was asked about my use of traditional or alternative
treatments.
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National Quality Center (NQC)
Using QI to Improve Cultural Competence
• Step One: Baseline Assessment
We know it’s a problem, is it our problem?
• Step Two: Deciding on an Aim
What are we trying to accomplish?
• Step Three: Defining Measures
How Will We Know a Change is An Improvement?
• Step Four: Planning and Testing Changes
What change can we make that will result in
improvement?
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National Quality Center (NQC)
Step Two: Deciding on an Aim
Question for the Panel
What would look different about your
programs after 3 or 4 (or 20?) years of
work on improving their cultural
competence?
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National Quality Center (NQC)
Step Two: Deciding on an Aim
What Do We Want to Accomplish?
• Reduce HIV transmission in communities of
color
• Reduce disparities in health outcomes
• Improve retention in care
• Access to care
• Satisfaction with care
• Strengthening organizational cultural
competence infrastructure
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National Quality Center (NQC)
Using QI to Improve Cultural Competence
• Step One: Baseline Assessment
We know it’s a problem, is it our problem?
• Step Two: Deciding on an Aim
What are we trying to accomplish?
• Step Three: Defining Measures
How Will We Know a Change is An
Improvement?
• Step Four: Planning and Testing Changes
What change can we make that will result in
improvement?
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National Quality Center (NQC)
Panel Question: Measurement
• Given that many important aspects of care aren’t
practical to measure, what kind of measurements
would you find believable clues to how well your
program is doing serving people of color?
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National Quality Center (NQC)
Step Three: Defining Measures
How Will We Know a Change is An Improvement?
Look for overall improvement AND
narrowing of racial and ethnic gaps in:
 % of patients undetectable on ARVs, by race
and ethnicity
 % of clients with broken appointments, by
race and ethnicity
 % of patients diagnosed with AIDS within one
year of HIV diagnosis
 % of patients satisfied with the language
services they received
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National Quality Center (NQC)
Local Example: What we learned
• #1 Just getting the data is hard! But worth it…
• What we learned from cultural competence questions:
 We are doing well with language access: <1% patients report they got
services in the language they wanted rarely or never.
 We need to look at our clinic environments: About 30% of Latinos
& A/PI report they rarely or never see waiting room materials that
“look like me”
 We need to do better asking about traditional and alternative
therapies for all populations; A/PI (29%) and whites (20%) are
especially unlikely to be asked about these.
 We especially unlikely to ask whites about their health beliefs
(>35% rarely or never asked).
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National Quality Center (NQC)
Using QI to Improve Cultural Competence
• Step One: Baseline Assessment
We know it’s a problem, is it our problem?
• Step Two: Deciding on an Aim
What are we trying to accomplish?
• Step Three: Defining Measures
How Will We Know a Change is An
Improvement?
• Step Four: Planning and Testing Changes
What change can we make that will result in
improvement?
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National Quality Center (NQC)
Step Four: Question for the Panel
What Domains for Change Are You Working In?
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Outreach/getting people into services
How care sites look and feel to patients
How enrollment and intake are organized
Involvement of families and other supporters
How patients/clients are involved in their own care and in design
of care,
• Where care facilities are located,
• Who might provide care: skill mix/experience
• Who your programs would partner with.
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National Quality Center (NQC)
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National Quality Center (NQC)
Putting it All Together: Testing and
Implementation
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National Quality Center (NQC)
General Cultural Competence Resources
• A Guide to Addressing Cultural Competence as a Quality
Improvement Issue in HIV Care
http://www.nationalqualitycenter.org/home/quality-improvementresources/conducting-quality-improvement-activities.cfm/15189
• Cultural Competence Resources for Healthcare Providers
http://www.hrsa.gov/servicedelivery/default.htm
• 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
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National Quality Center (NQC)
References from Slide 9
• 1. Losina E, Schackman R, Sadownik S, et al. Disparities in survival
attributable to suboptimal HIV care in the US: Influence of gender and
race/ethnicity [abstract 142]. Presented at: 14th Conference on
Retroviruses and Opportunistic Infections; February 25-28, 2007; Los
Angeles, California.
• 2. Wilson Lucy, Korthuis P, Conviser R, et al. Rural Versus Urban
HIV/AIDS Clinical Outcomes: A Multi-state Perspective [abstract 974].
Presented at: 14th Conference on Retroviruses and Opportunistic
Infections; February 26, 2007; Los Angeles, California.
• 3. Hartzell J, Spooner K, Howard R et al. Race and mental health
diagnosis are risk factors for Highly Active Antiretroviral Therapy failure
in military cohort despite equal access to care. Journal of Acquired
Immune Deficiency Syndrome. 2007; 44(4): 411-416.
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National Quality Center (NQC)
National Quality Center (NQC)
NYSDOH AIDS Institute
90 Church Street—13th Floor
New York, NY 10007-2919
888-NQC-QI-TA
[email protected]
NationalQualityCenter.org
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National Quality Center (NQC)