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 |
| 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 |