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Table 3 The approaches inserted in the analytic framework

From: How should health service organizations respond to diversity? A content analysis of six 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
 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 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
 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 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
*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
   *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