Organizational Cultural Competency
Brief Self-Assessment Tool
About your organization
A. Organization name ______________________________________________________
B. Total number of practice sites _______
C. Number of practice sites serving a racially/ethnically diverse population ______
D. Number of primary care physicians (PCPs) _____
E. Percent of PCPs who have completed cultural competency training ____
F. Number of Primary Care Nurse Practitioners/Physician Assistants _______
G. Percent of these NPs/PAs who have completed cultural competency training ______
H. Number of specialist physicians _______
I. Percent of specialists who have completed cultural competency training ______
I. Governance, Leadership, and Workforce
1. Our organization ensures that the necessary fiscal and human resources including cultural tools, skills, and
knowledge are a priority in our organization.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments___________________________________________________________________________________________
____________________________________________________________________________________________________
2. Our organization’s recruitment, hiring, and retention practices achieve a diverse and culturally competent staff,
including senior leadership, reflective of our patient/client population.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments___________________________________________________________________________________________
____________________________________________________________________________________________________
3. Our organization requires diversity awareness and cultural competence training at all levels of the organization
(i.e., staff, management, providers, etc.).
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments__________________________________________________________________________________________
II. Communication and Language Assistance
4. Our organization provides language assistance services at no cost to the patient/client.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments__________________________________________________________________________________________
____________________________________________________________________________________________________
5. Our organization posts notification of the right to an interpreter in several languages at various points of contact
and by various means (print and multimedia).
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments__________________________________________________________________________________________
___________________________________________________________________________________________________
6. Our organization does not use family members, friends or minors for providing interpretation for a patient/client
appointment.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments__________________________________________________________________________________________
___________________________________________________________________________________________________
7. Our staff understands and respects the cultural health and illness beliefs and practices of our patient population,
including beliefs about complementary and alternative medicine and medical treatments that may violate cultural
and/or religious traditions.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments_______________________________________________________________________________________
________________________________________________________________________________________________
8. Our organization assures that the patient education materials we use are culturally appropriate for our patient
populations and are available in their preferred language.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments__________________________________________________________________________________________
____________________________________________________________________________________________________
9. We explain technical or specialized terminology and make every effort to assure that our patients fully
understand questions, instructions and explanations from our clinical, administrative and other staff. Our staff are
expected to assess patients’ understanding by asking questions or having the patient repeat the information in their
own words.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments__________________________________________________________________________________________
___________________________________________________________________________________________________
10. Our organization has a designated process for assuring that our printed patient/client materials are written in
plain language and adhere to health literacy guidelines.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments________________________________________________________________________________________
__________________________________________________________________________________________________
Engagement, Continuous Improvement, and Accountability
11. Our organization has a strategic plan that incorporates Culturally and Linguistically Appropriate Services
(CLAS) goals and activities.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments________________________________________________________________________________________
__________________________________________________________________________________________________
12. Our organization has developed measurable outcome goals regarding cultural and linguistic competence and
periodically assesses our progress in meeting those goals.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments________________________________________________________________________________________
__________________________________________________________________________________________________
13. We have identified a CLAS/cultural competency champion from within our staff to monitor our activities and
advancement in cultural competency
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
What is the name of this individual?_______________________________________
Comments________________________________________________________________________________________
__________________________________________________________________________________________________
14. Our organization collects race and ethnicity, preferred language, and disability status for all of our patient/clients.
(If you collect 2 out of 3 enter “Agree”)
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments________________________________________________________________________________________
__________________________________________________________________________________________________
15. Our organization measures clinical quality of care by race/ethnicity and language and identifies disparities in the
care received by different population groups.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments________________________________________________________________________________________
__________________________________________________________________________________________________
16. Our organization measures patient experiences by race/ethnicity, language and education to assess access,
communication, coordination of care and patient engagement.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments________________________________________________________________________________________
__________________________________________________________________________________________________
17. Our organization works to address identified disparities in care and service and to meet the social and health
needs of our community.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments________________________________________________________________________________________
__________________________________________________________________________________________________
18. Our organization has a formal grievance/complaint process that is accessible to all patient/client populations.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments________________________________________________________________________________________
__________________________________________________________________________________________________
19. Our organization regularly provides information to the public through print materials and activities highlighting
our efforts to provide culturally responsive care to all patient/clients.
Strongly
agree
Agree
Disagree
Strongly
disagree
Don't
know
N/A
Comments________________________________________________________________________________________
__________________________________________________________________________________________________
20. Please provide one example of a policy, project, process or program that you have implemented in the last 12
month to address the cultural or linguistic needs of your patient population.
Thank you for taking this Organizational Cultural Competency Self-Assessment.