Standard 9: Organizational Self-assessment (guideline and recommendation)

“Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural
and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations.”

Under ideal circumstances, organizational self-assessments should address all the activities called for in the 14 CLAS standards. To begin the process, an initial self-assessment—reviewing organizational policies, practices, and procedures—will be necessary before proceeding to develop and implement the strategic plan outlined in Standard 8. Then, continuous self-assessment should assess the progress being made in implementing all the standards. This continuous organizational self-assessment aims to gather baseline and unfolding information needed:

  • To define service needs
  • To identify opportunities for improvement
  • To develop action plans
  • To design programs and activities

This self-assessment process is, in effect, a classic SWOT (strengths, weaknesses, opportunities, threats) analysis of the organization’s capacities, strengths, shortcomings, and challenges in developing an institutional focus on CLAS.

The Role of Organizational Self-Assessment
The ongoing organizational self-assessment process can reveal factors that could interfere with the organization’s effective delivery of CLAS. A cultural audit, a specific form of organizational assessment, focuses on identifying problems and developing relevant strategies to address them. Unfortunately, many organizations are not sufficiently aware of internal structural and behavioral factors that interfere with providing quality CLAS. Some healthcare organizations’ efforts to provide targeted CLAS programs stop short of linking these efforts to policies and decision making related to accountability of outcomes. However, there are steps that organizations can take to assess their progress.

Conducting a cultural audit to review policies, procedures, and practices should be the first step. Existing cultural competence assessment tools can provide general guidance to determine whether the core infrastructure for providing CLAS—management, governance, delivery systems, customer relations—is currently in place. The cultural audit can identify:

  • Assets, such as bilingual staff members who could serve as interpreters and current relationships with community-based organizations
  • Weaknesses, such as lack of translated signage or cultural competence training
  • Opportunities for improvement, such as revising the mission statement or recruiting people from diverse cultures into policy and management positions

Such a self-assessment can empower the organizations to develop strategic plans for providing CLAS (see Standard 8). Ongoing self-assessment can track progress in implementing the standards and refine strategic plans as needed.

Tools for Organizational Self-Assessment
There are a variety of tools available for organizational self-assessment, but they have not been specifically validated against one another. In addition, some tools are more suitable to particular types of institutions (eg, hospitals or managed care organizations), and none of them are based on the CLAS standards. For a sample compilation of cultural assessment tools, please see Transcultural C.A.R.E. Associates’ list: Another key resource to locate self-assessment tools can be found by visiting the National Center for Cultural Competence’s website:

CLAS-Related Measures in Performance Improvement and Outcomes Assessments
Integrating cultural and linguistic competence measures into existing quality improvement programs could provide one way to assess whether CLAS delivery processes are having the intended outcomes. However, there is currently no consensus on state-of-the-art measures of CLAS quality, satisfaction, and outcomes. Still, organizations have some avenues to collect basic data about clients’ utilization of CLAS and to analyze the quality of these services and their outcomes. For example, organizations could conduct focused studies that explore:

  • Accessibility of interpreter services
  • Effectiveness of cultural competence training for providers and nonclinical staff
  • Differences in the use of services among different racial and ethnic groups
  • Impact of providing culturally competent services on the health outcomes, health status, and satisfaction of enrollees

Similarly, performance improvement programs could include evaluation questions focusing on whether there are differences among ethnic or language groups in service utilization (eg, failure to appear for appointments, termination of enrollments). Such data can be used to refine programs by identifying problems that can be easily addressed. For example, by determining why certain times are less convenient for patients from a particular group, an organization could adjust appointment times and improve access to services among the group.

Adding a question about self-identified ethnicity to existing patient surveys can provide a way to integrate cultural competence-related measures into performance improvement activities. These data can be used to compare patient satisfaction among ethnic groups and to identify specific service-related differences. Collecting these data, however, must be done in a culturally and linguistically appropriate way, with translated questionnaires or bilingual interviewers for telephone surveys.

Although patient satisfaction surveys are a common method to evaluate services, they may not produce an accurate view of the quality of services. Designing patient satisfaction surveys that capture a patient’s complete attitude toward quality and satisfaction can be quite challenging. For example, neither patients nor clinicians may be able to appropriately assess the quality of language assistance services because neither has the linguistic skills to verify the competency of the interpreter or the accuracy of the translation. Another factor is the wide cultural variations in how clients respond to satisfaction-related questions, especially if their feedback may be negative.

Assessing the efficacy of CLAS on health outcomes requires aggregate data on patient race and ethnicity, but such data should not be aggregated only on the basis of last names—a common practice in efforts to compile ethnicity statistics. The last-name approach does not capture:

  • Overlaps that occur between subpopulations (eg, Cuban Americans and Mexican Americans)
  • The reality that immigrants often change the spelling of their last names
  • The possibility that marriage-related changes may reduce the accuracy of last names as markers of ethnicity

Nevertheless, collecting race, ethnicity, and language data is necessary to ensure appropriate monitoring of patient-service needs and utilization, quality of care, and outcome patterns. A more complete discussion of this need can be found in Standard 10.






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