Standard 8: Organizational Framework for Cultural Competence (guideline)
“Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.”
To implement the CLAS standards successfully, an organization must be able to direct its attention and resources to the needs of culturally diverse populations—ie, to plan strategically. In doing strategic planning, an organization seeks to define and structure activities, develop policies, and set goals that will empower it to provide culturally and linguistically appropriate services.
Policy Basis for a CLAS Organizational Strategy
Both regulatory and internal policies support the need for having a
CLAS-specific organizational strategy. That strategy is key to planning and implementing cultural and linguistic competence activities. A well-developed strategy should include:
- Service activities, time lines, and milestones
- Identification of responsible individuals (using detailed organizational charts)
- Development and implementation of standards and performance requirements
- Performance monitoring
- Protocols for scheduling and coordinating activities
The Office for Civil Rights (OCR)—recognizing that lack of formal
structures to organize and deliver CLAS services is a major impediment to adequately
serving diverse population—explicitly calls for this type of strategic planning to facilitate compliance with Title VI. For example, having qualified interpreters and translated materials available when they are needed would hardly be possible if there are not staff designated to be responsible for planning and delivering those services.
With a sound strategic plan, cultural competence should be reflected at every level of a healthcare organization and should be visible in both obvious and subtle ways. A culturally competent organization would go far beyond the provision of services called for in the CLAS standards. Examples might include the presence of culturally diverse reading materials in waiting and treatment rooms, display of culturally diverse artwork and posters, and offering diverse food choices in cafeterias and vending machines.
Organization-wide Integration of CLAS
Having well-developed CLAS goals and policies along with delivery of CLAS activities requires a careful balance. That is, cultural competence should be thoroughly integrated into the life of an organization. This means that cultural competence should rest on a philosophical and ethical basis, and not be limited to policies, rules, and strategies that address culturally and linguistically appropriate services. A vital first step is to incorporate CLAS activities and values into an organization’s mission statement and its comprehensive management strategy.
Accountability from the Top and Throughout the Organization
To assure accountability and durability of CLAS, it must receive the support of top management—including an organization’s board of trustees or directors—and responsibility for implementation must be shared throughout the organization. A board that is committed to organizational cultural competence can drive change across the organization, even when department chairs and managers are not prepared to move forward. Nevertheless, at some facilities the front-line providers may be the motivators for implementing CLAS; these staff members can become frustrated if they cannot adequately communicate with patients or they see the same patients regularly due to an inability to understand a provider’s instructions. When staff begin to develop culturally competent services, they may acquire CLAS expertise and authority among peers, leading to being asked by administrators to provide guidance on CLAS standards throughout the organization.
Wherever the motivation for change toward greater cultural competence originates, competence policies should be followed at every level of the organization, with each person participating in both the philosophy and the practice. To establish and maintain such thoroughness, some organizations may wish to create an office of diversity, to assign cultural competence as part of the job responsibilities of a senior manager, or to establish a cultural competence team for the entire organization. A cultural competence committee need not be charged with actually doing training. Rather, they can meet with supervisors to review issues encountered in their departments and then work with the organization’s training department to develop curricula and activities.
Implementation of CLAS Activities
An organization that currently has limited experience in CLAS health services may feel intimidated by the prospect of acting on the 14 CLAS standards. For this reason, organizations should move forward incrementally with implementing the standards and regard the effort as a developmental process that will take place over an extended time. When developing a comprehensive plan that incorporates values, structures, policies, practices, and procedures at all levels, a healthcare organization should include incremental, measurable short-term and long-term results. Although step-by-step guidelines or a toolkit specifically for implementing CLAS standards is not currently available, healthcare organizations could initially focus on implementing 1 or 2 of the standards. Another approach would be to design a standard-by-standard implementation process, with each step building on the previous one. A sample implementation sequence could work as follows (with relevant CLAS standard number in parentheses):
- Laying the groundwork:
- Internal assessment (9)
- Community profile (11)
- Community engagement (12)
- Organizational supports:
- Plans and accountability structure (8)
- Data collection systems (10)
- Language assistance (4, 5, 6, 7)
- Staff diversity and cultural competence training (2, 3)
- Culturally sensitive care and environment (1)
- Ongoing assessment: organization and staff (3, 9)
- Outcomes research and evaluation (9)
The complexity of this suggested implementation process clearly reinforces the need for the kind of organizational framework discussed in Standard 8—implementing and managing CLAS activities could not happen without a strategic approach.
Involvement of Communities and Patients
An important feature of Standard 8 is the need to involve communities and patients in developing an organization’s strategy for cultural competence (see Standard 12 for a more complete discussion). Consumer representation on the boards of directors of federally funded community health centers is mandated, but many other organizations lack arrangements to involve communities throughout CLAS planning and implementation. However, organizations could turn to the close ties that they cultivate and the regular meetings they sponsor among consumers and community leaders to seek input on ideas and feedback on services. Although the challenges of developing the type of strategic planning called for in Standard 8 are significant, failure to provide well-conceived, effective CLAS activities will undermine a healthcare organization’s value in its community.