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Developing a Research Agenda for Cultural Competence in Health Care:
Organizational Supports For Cultural Competence
Draft research agenda--version 1.0

Resources for Cross Cultural Health Care
and the U.S. Department of Health and Human Services
Office of Minority Health and the Agency for Healthcare Research and Quality

We invite public input on our draft research agendas. Please read the following document and send your comments to rcchc@aol.com. We are especially looking for recommendations for additional research questions and methodological/policy considerations. We are also seeking additional bibliographic references for the literature review abstracts. Comments received by December 10 will be incorporated into the final report–comments will also be posted online.

Definition

The CLAS standards report describes two levels of cultural competence activities: cultural and linguistic competence interventions that directly involve or affect the patient or provider; and activities that can be undertaken at the organizational level to support the delivery of cultural competence interventions. This topic area focuses on the organizational supports or accommodations. The specific organizational supports^* described by the CLAS standards include the following:

• written strategic plans that outline clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.
• initial and ongoing organizational self-assessments of CLAS-related activities
• integration of cultural and linguistic competence-related measures into internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations.
• collection of data on patient/consumer race, ethnicity, and spoken and written language in that is documented in health records, integrated into the organization's management information systems, and periodically updated.
• current demographic, cultural, and epidemiological profiles of the community as well as needs assessments to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.
• participatory, collaborative partnerships with communities and formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities.
• conflict and grievance resolution processes that are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.
• public information about progress and successful innovations in implementing the CLAS standards and public notice in communities about the availability of this information.

Because implementing these types of activities requires considerable effort and resources from healthcare organizations, there is a natural desire to know whether taking these steps has a positive impact on the efficient implementation of cultural competence interventions, patient and staff satisfaction, appropriate utilization of services, the cost-effectiveness of services, the quality of services, and other desirable measures.

* For additional details about the organizational supports described here, please consult the text, commentary, and discussion on CLAS standards #8-14, available online at www.omhrc.gov/CLAS

The following discussion will combine the synthesis of findings from current literature and recommendations for key research questions for each of the organizational supports in the bulleted list above. The last section will address research and policy considerations for further work on the entire topic area.

Synthesis Of Findings From Current Literature And Key Research Questions

In general, there is considerable experience in the implementation of a number of clinical cultural competence interventions in a variety of different types of healthcare settings. Some of those settings have conducted basic evaluations of their programming, and others need assistance from researchers to design and develop evaluations or outcome studies. At this time, very little published research specifically examining the processes and outcomes of organizational accommodations for cultural competence was found. The literature described single activities (as opposed to systemic interventions) that can be institutionalized at an organizational level such as the development of information systems, implementation of training and staffing. Most of the following discussion outlines areas of research that might help us better understand the benefit of these accommodations.

Management, Policy And Implementation Strategies To Institutionalise Cultural Competence Activities

Synthesis of findingds from current literature

The literature consists primarily of descriptions of different approaches to implementing cultural competence activities in an organization, with very little analysis of outcomes. Two studies examine a variety of different factors and forces that led to successful and unsuccessful implementation of cultural competence interventions.

Key research questions

In general, considerably more information is needed that documents the step-by-step processes of implementing cultural competence activities, as well as evaluations of what processes are more successful than others. Further work investigating the barriers and supports for successful implementation programs is also necessary. Other issues worth investigating include:

• What factors or forces encourage management to commit to cultural competence (regulatory, community pressure, staff pressure, market-expansion)? Or does it get adopted into the organization through other channels (e.g. staff-driven efforts to implement different activities in a piecemeal approach)? Which organizational strategies are most likely to succeed? What are the barriers or limitations to the adoption of cultural competence strategies (cost, time, resource allocation, staff, lack of expertise)?
• Does the existence of explicit plans and strategies for implementation of cultural competence interventions facilitates and improves the delivery of those services over an ad hoc approach? Are there any organizational preconditions or critically necessary management or policy components required to accomplish outcomes?
• What is the financial cost of implementing a comprehensive, organization-wide approach to cultural competence, such as described in the CLAS standards (including a determination of administrative burdens)? What cost-benefit if any is there to the organization, and over what period of time?

Community Involvement In Program Planning, Design, Implementation, Training, And Research

Synthesis of findingds from current literature

Many stakeholders have postulated that involving ethnic communities in the design of programs will lead to higher satisfaction and better utilization of services. Community input mechanisms that have been described in literature include surveys, telephone and in person interviews, focus groups, community meetings, community advisory committees, community members on standing organizational committees, community member participation in program design and evaluation committees.

The studies describe a variety of mechanisms for involving community members in the development of different organizational supports for culturally competent activities (clinical training, survey design, health promotion program design, developing community profiles). All the authors described positive results (including increased acceptability of the surveys and response rates) from their efforts, although these conclusions appear to be presumed and not formally measured. No attempts were made to test their methods against other approaches.

Key research questions

What are the desirable, measurable outcomes of involving community input at the organizational or programmatic level? What mechanisms of input maximize which outcomes?

• Does having ethnic community advisory committees or other mechanisms of community input have a measurable and beneficial effect on the successful implementation and acceptance of plans, policies, and programs of culturally competent interventions, either at the organizational or programmatic level? What are effective models for soliciting input to inform organizational strategic planning, and to what extent is this information taken seriously in subsequent decision-making processes?
• Does the existence of community input mechanisms improve the perception of a healthcare organization among the community, and/or result in increased utilization of services?
• Are there adaptable models of community input that are replicable, and what are the critical components of such models?

Design And Use Of Surveys And Profile Instruments To Plan For Services And Measure Satisfaction, Quality Of Services

Synthesis of findingds from current literature

Four descriptive studies examine multifaceted processes of developing survey instruments that are culturally appropriate for the purposes of gathering information to design and deliver health services. Quantitative and qualitative methods are to gather relevant cultural information for the purposes of survey design, pilot testing and modification and of the tool.

Key research questions

• What level of community input, data gathering and testing is necessary to develop culturally valid tools for information gathering, as many healthcare organizations have neither the time nor resources to engage in complex survey development processes for the purposes of service planning and design. Are there model instruments or templates that can be easily adapted? Is the process of involving the community in survey design as important as the implementation of an acceptable tool?
• What kinds of information do organizations need in order to develop culturally appropriate and programs and systems? How does one develop valid tools to gather information on patient satisfaction and within programs, given the difficulty of reliably measuring satisfaction across ethnic groups?

Health Information Support For Cultural Competence

Synthesis of findingds from current literature

One descriptive article was found on developing a cross-cultural health information system to support providers and patients with information about the cultural beliefs and practices of different ethnic communities.

Key research questions

• Does the availability of such information systems result in beneficial utilization by providers and patients, and is this information is incorporated into practice or behaviour change? What information delivery systems are most acceptable and most reliably used?
• What are best practices in providing information about cross-cultural healthcare and cultural competence issues for everyday use by providers and staff?

Cultural Competence Self Assessments

• What impact does the implementation of organizational self-assessments have on:
• staff perception of cultural competence and the needs of culturally diverse populations;
• motivating improvements on cultural competence within the organization;
• improving the quantity and quality of cultural competence services over time;
• overall organizational strategic planning?
• What remains to be done to develop valid and reliable instruments to assess organizational cultural competence? Is it possible and/or desirable to develop instruments that compare cultural competence across organizations, or do we want to simply be able to measure cultural competence within a single organization?

Ethnic Data Collection/Community Profiles

• What level of race, ethnicity and language data is needed to adequately plan for the delivery of culturally competent services in healthcare organizations? What mechanisms can be most efficiently implemented to facilitate the collection of this data?
• Does the easy availability of r/e/l data improve the timely delivery of culturally competent services, such as interpretation or translated materials?
• What adjustments to management information systems are necessary to integrate r/e/l data with other institutional data that would reveal trends in health status and outcomes?
• What are the resistance factors to providing, collecting and utilizing r/e/l data among both patients and health care providers? Are there ways these concerns can be allayed? What type of training and/or information is needed to improve attitudes and practices towards data collection practices?
• What is the impact of the absence formal policy related of r/e/l data collection at the time of enrollment and/or clinical care intakes?
• Examine organizations with formalized r/e/l data collection policies and practices to see if such mechanisms enhance the organization’s ability to target different populations and better plan quality improvement in an effort to address disparities.

Culturally Appropriate Ethics, Conflict, And Grievance Resolution Processes

More descriptive studies are needed about the kinds of cultural issues that arise in clinical ethics, conflict, or grievance situations. Research by Kauffert suggests that even well-trained interpreters who are familiar with professional standards of conduct encounter difficult cultural and ethical conflicts in the context of dealing with complex clinical situations. These situations may arise around truth-telling related to terminal diagnoses (unacceptable in many cultures) or other diagnosis or treatment issues that may put Western biomedical perspectives into conflict with traditional beliefs.

• What models exist to facilitate the discussion and resolution of culture-related conflict situations, and are they culture-specific or usable across ethnic groups?
• How can staff be best prepared for dealing with these situations in a way that minimizes the danger to clinician-patient trust, and what institutional policies work best to support staff and patients, especially in environments where many cultures are being served?

Public Information About CLAS Standards Performance

• What kinds of information do ethnically diverse populations want, need and use to make decisions about choosing healthcare providers and healthcare organizations? Do issues of cultural and linguistic competence enter into the decision-making process? How can this information best be presented (formats)?

Implementation Of The CLAS Standards

• What is the business case for instituting CLAS?
• What is the financial cost of implementing the standards?
• What is the administrative burden of putting these standards in place? Are there other non-cost barriers to accepting the implementation of CLAS activities?
• Will integration of standards put an organization into a deficit position or does non-compliance put an organization into a deficit position?
• Can CLAS be integrated into other efforts rather than exist as a competing effort?

Research And Policy Considerations For Further Work In This Area

Education and incentives are needed to persuade health care organizations to participate in research on cultural competence, especially research that pertains to organizational practices. The current demand is for institutions to spend their time and resources on questions that have a clinical focus. Research may also be complicated by the lack of awareness that many organizational decision makers have about the cultural competence activities going on outside the realm of formal policy directives. Current government regulations that require a minimal burden on potential survey respondents or organizational research participants severely hamper or restrict the ability of Federally-funded researchers to conduct many types of thorough assessments. Difficulties around race/ethnicity/language data collection have an impact on the ability to conduct research in this area (beyond the affects of services planning or outcomes tracking). Many organizations perceive financial, legal, financial, and logistical barriers to such data collection. The lack of standardized race/ethnicity data collection mechanisms significantly hamper cross-organization comparisons.

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