Cultural Competence as a Quality Issue: Practical Next Steps to Improvement Technical Assistance Call 11/12/08

Road Map for the Call Faculty Introductions Getting cultural competence on the quality agenda Making progress using the Model for Improvement Faculty real world experiences Tips and ideas Resources for more research And your Q and A and comments throughout the call. KAC will do this intro

Faculty Introductions Kathleen Clanon, MD kclanon@jba-cht.com NQC Consultant Nancy Koughan, D.O., M.P.H. nskoughan@dhr.state.ga.us Lead Physician, Early Care Clinic, DeKalb County Board of Health, GA Daniel Barba, JD dbarba@mail.cho.org Program Manager, Family Care Network, Oakland Patricia Calloway, RN Patricia.Calloway@acgov.org QM Coordinator, Part A, Oakland CA Hela Issaq, MPH helaissaq@gmail.com QM Coordinator, Part C and D, Oakland (ret.) Nancy Halloran, MSW nshalloran@sonic.net Program Planner Part C and D, Oakland I will ask each of you to say who you are and a bit about why this topic is imortant to you. A personal story is good. Should be 1-1.5 mins.

Name Confusion Cultural Compentence Cultural Competency Cultural Humility Cultural Fluency Culturally Affirmative Practice Cultural Proficiency Before we go any further, I want to acknowledge that the terminology in this area is changing. You may be used to using one of these other phrases on this list; each has strengths and weaknesses as a descriptor. We’ve chosen to use “cultural competence” because that is the most common term and because it is what HRSA/HAB uses.

HRSA Uses: “Cultural Competence” “Cultural competence is a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations.” HRSA Care Action Bulletin 2002 Whichever term you use, what we are talking about is this. Cross et. al. 1989 and Lavizzo-Mourney and Mackenzie 1996 as cited in Cultural Competence: A Journey, Bureau of Primary Health Care. Health Resources and Services Administration, US Department of Health and Human Services, n.d.)

Using QI to Improve Cultural Competence Step One: Getting Cultural Competence on the quality agenda. We know it’s a problem, but is it our problem? Step Two: Deciding on an Aim What are we trying to accomplish? Step Three: Defining Measures How Will We Know a Change is An Improvement? Step Four: Planning and Testing Changes What change can we make that will result in improvement? Now that we decided on what to call it, how are we going to approach improving cultural competence. You will probably recognize the M for I in steps 2, 3, and 4 here, but we are going to start with an earlier step and ask, how do you even get your organization to agree that cultural competence is a quality problem?

Step One: Getting Cultural Competence on the Quality Agenda Panel Question: What made your organization decide that you needed to work on cultural competence? Address baseline assessment—Dan and Dr. K Consider mentioning CLAS standards, that staff brought it up in meetings, that patients, complained about their services, that we were worried about people lost to care. We wanted to do something, but didn’t want to waste time with one-off cult comp trainings…..

National data showing disparities in care and outcomes. What might make organizations put cultural competence on the Quality Agenda? National data showing disparities in care and outcomes. Local complaints or concerns Formal baseline assessment of your organization’s cultural competence Federal requirements: National Standards for Culturally and Linguistically Appropriate Services (CLAS Standards) www.omhrc.gov/assets/pdf/checked/finalreport.pdf Depending on your program, familiarity with national data about HIV disparities might be enough to put disparities and cultural competence on the quality agenda. In other situations, a consumer’s personal story or reports of complaints or concerns about program language capabilities or staff and client mismatches may be a starting point for a disparities assessment. If your program is part of a larger organization with many competing priorities, you may have trouble getting HIV disparities on the quality agenda. If so, you can refer to the Federal Standards on Culturally and Linguistically Appropriate Services. The CLAS standards address the importance for health organizations of knowing about and collaborating with the ethnic communities they serve. Any organization receiving Federal funds (including Ryan White Program grantees) is required to comply with the part of the standards that address language services.

National Data: Disparities in Care Entry into Care: African-Americans and Latinos are likely to be diagnosed at a later disease stage than whites1 Starting Treatment: African-Americans in one large national sample study were 59% less likely than whites to be receiving HAART2 Success with Treatment: 63% of African-Americans had an undetectable viral load after one year of treatment vs 92% of whites. These are examples of the kind of data that your program might consider. Nationwide, people of color are likely to be diagnosed in later stages in HIV illness and, as these example studies illustrate, they may be less likely to be taking antiretroviral (ARV) treatment once in care; African-Americans in one large national sample study were 59% less likely than whites to be receiving HAART.2 Once on ARV treatment, minority patients in many studies are less likely to show virologic success; 63% of African-Americans had an undetectable viral load after one year of treatment vs 92% of whites in this study from the military published in 2007. See references on end slide 9

Local Complaints and Concerns patient complaints of different treatment based on race or primary language. staff complaints of culturally-based conflict. concerns about demographic mismatches between staff and clients. different rates of retention in care between groups. Have you seen any red flags like this in in your program? Local complaints and concerns might come up at consumer input sessions, among staff within an agency or between agencies, or just show up as red flags like demographic mismatches and different retention rates.

Formal Baseline Assessments of Cultural Competence Organizational Self-Assessment Knowing the community you serve Ability to collect data on race, ethnicity and primary language Hiring and training policies Translation and interpretation services Assessing and addressing health beliefs (http://www.aidsetc.org/doc/workgroups/cc-question-bank.doc) Patient Input Survey, focus groups, CABs As with any quality effort, you will need data to guide the work you do on cultural competence and disparities. Both quantitative and qualitative data can be useful as a starting point. One useful strategy is to start with a three-tier assessment; bringing together patient input on the issue, doing a qualitative review of your organization’s cultural competence infrastructure, and drilling down into your existing performance data to break out results by group.

Example: Patient Satisfaction Survey Cultural Competence Questions In the 2008 client satisfaction survey in Oakland, these questions were included: I got services in the language I wanted. The staff asked about my health beliefs during my visits. The waiting room has materials that show people from my racial or ethnic group. The staff at the clinic show respect for my religious beliefs. I was asked about my use of traditional or alternative treatments. Hela will talk about we decided to get input from our consumers, needed to focus the questions so they would be useful. Here’s what we came up with. Will share the results with you in a slide coming up. You could add these or other questions to your existing survey, or you might consider doing a focused survey of clients asking specific questions about how they experience the cultural competence of your agency, such as “Do you feel welcome in this clinic or do you feel like an outsider? Have you ever felt like you might get better care at your clinic if you were from a different racial or ethnic group?”

Using QI to Improve Cultural Competence Step One: Baseline Assessment We know it’s a problem, is it our problem? Step Two: Deciding on an Aim What are we trying to accomplish? Step Three: Defining Measures How Will We Know a Change is An Improvement? Step Four: Planning and Testing Changes What change can we make that will result in improvement? Moving to step two. Now that your organization has decided to make cultural competence part of its quality agenda, what is it exactly that you are working toward; what is the program’s improvement AIM?

Step Two: Deciding on an Aim Question for the Panel What would look different about your programs after 3 or 4 (or 20?) years of work on improving their cultural competence? Dan and Patricia: comment on how a culturally comp org would be different than today. Consider commenting in a practical, specific way on how outcomes, access, retention in care, experience of care in terms of everyone feeling welcome and reduced stigma, etc. Will be different.

Step Two: Deciding on an Aim What Do We Want to Accomplish? Reduce HIV transmission in communities of color Reduce disparities in health outcomes Improve retention in care Access to care Satisfaction with care Strengthening organizational cultural competence infrastructure Your data and the nature of the services you provide will determine what kind of aim you might use; here are some likely categories: Reduced disparities in health outcomes, for example, a Part C or D program might work to reduce gap between groups in rates of undetectable viral load. Retention in care- for example a Part B program might improve a disparity in % of clients from different groups who fail to recertify for ADAP Access to care – an EMA or TGA or State might on a problem of late entry into care or % of patients from different groups who are lost between testing and care sites Satisfaction with care - improving satisfaction with care for particular racial, ethnic or language groups could be an aim for any level program, as could Strengthening Organizational cultural competence infrastructure.

Using QI to Improve Cultural Competence Step One: Baseline Assessment We know it’s a problem, is it our problem? Step Two: Deciding on an Aim What are we trying to accomplish? Step Three: Defining Measures How Will We Know a Change is An Improvement? Step Four: Planning and Testing Changes What change can we make that will result in improvement? OK, now we know where we are headed for. How do we know we are making progress?

Panel Question: Measurement Given that many important aspects of care aren’t practical to measure, what kind of measurements would you find believable clues to how well your program is doing serving people of color? Going back to our panel, Dr. K and Patricia, how would you/are you approaching measuring the cultural competence or relevance of your programs? (consider talking about pat satisfaction, input of CAB, adherence to CLAS standards, etc)

Step Three: Defining Measures How Will We Know a Change is An Improvement? Look for overall improvement AND narrowing of racial and ethnic gaps in: % of patients undetectable on ARVs, by race and ethnicity % of clients with broken appointments, by race and ethnicity % of patients diagnosed with AIDS within one year of HIV diagnosis % of patients satisfied with the language services they received Here are some examples of how you can tell if your changes have made an improvement. The narrowing of racial and ethnic gaps in the percent of patients who are undetectable on ARVs would be a health outcome improvement. The narrowing of gaps in the percent of clients with broken appointments, and in the % of patients presenting with an AIDS diagnosis within 1 year of first HIV test would be an improvement in retention in care. Improvement in the percent of patients using interpreter services who are satisfied with the language services they received is an improvement in satisfaction with care.

Local Example: What we learned #1 Just getting the data is hard! But worth it… What we learned from cultural competence questions: We are doing well with language access: <1% patients report they got services in the language they wanted rarely or never. We need to look at our clinic environments: About 30% of Latinos & A/PI report they rarely or never see waiting room materials that “look like me” We need to do better asking about traditional and alternative therapies for all populations; A/PI (29%) and whites (20%) are especially unlikely to be asked about these. We especially unlikely to ask whites about their health beliefs (>35% rarely or never asked). This slide will have the data from our cultural compe survey questions. Hela will talk about our conclusions from the data, including: 1 How unexpectedly hard to get the data 2 good news­language access 3 beliefs and written materials for latinos I CHANGED THIS SEE SLIDE-NH 4 across the board asking about traditional and alternative therapies NOTE FEW API SO NOT SURE OF SIGNIFICANCE 5 health beliefs and whites an interesting finding. Explore more what this means­white people have culture too.

Using QI to Improve Cultural Competence Step One: Baseline Assessment We know it’s a problem, is it our problem? Step Two: Deciding on an Aim What are we trying to accomplish? Step Three: Defining Measures How Will We Know a Change is An Improvement? Step Four: Planning and Testing Changes What change can we make that will result in improvement? Finally, what ideas for change can be tested with PDSAs.

Step Four: Question for the Panel What Domains for Change Are You Working In? Outreach/getting people into services How care sites look and feel to patients How enrollment and intake are organized Involvement of families and other supporters How patients/clients are involved in their own care and in design of care, Where care facilities are located, Who might provide care: skill mix/experience Who your programs would partner with. For Dan and Dr. K: Can you give us an example from this list of a cultural competence change project or PDSA that you are working on or planning? This list can be a starting place to brainstorm possible changes. We are interested to hear if any of you have tried changes in any of these areas.

Your staff and patients or clients probably have a lot of ideas already about problems or areas to focus on to improve cultural competence of the program. One way to get everyone involved in thinking through possibilities for change is the fishbone diagram. This is one that was done by my program back home, considering why it was that we were seeing lower rates of virologic success in Af Am patients.

More Ideas for Changes to Test Goals Changes to Test Care Delivery Better communication with clients through improved understanding of their cultural health beliefs. Add questions about spiritual or religious beliefs to intake and develop a resource list of HIV-friendly local religious groups to give out. Have a staff member ask clients on HAART whether they have concerns about how the medications work for different racial groups. Add a question about clients’ use of alternative health treatments or practitioners. Improve clients’ trust and comfort with the program by reflecting the race/ethnicity of the people served. Hold a group visit with patients of the same race/ethnicity, to discuss nutritional habits, how these habits could contribute to disease status and offer culturally appropriate alternatives. Offer clients choices of whom to get adherence counseling from; include at least one staff member of the client’s race, where possible, and one non-professional/peer staff member. Improve patients’ access to interpreter services and materials in their primary language. Morning “huddle” of staff to highlight in advance which patients will need interpreters and notify/remind the interpreter services department. Include an assessment of health literacy as part of intake for all LEP patients. Consumer Involvement Incorporate consumers’ ideas and preferences by getting culturally-specific feedback and input from clients. Focus one CAB meeting on feedback about and improvements in the cultural competence of the organization. Ask clients after visits if cultural issues were discussed and whether they were satisfied with the provider’s sensitivity to their culture. Organization/Infrastructure Increase organizational awareness of cultural issues and accountability for addressing organizational weaknesses in this realm. Collect and report quality data broken down by race and ethnicity. Begin using an organizational assessment on a regular basis (at least once per year) and use it to decide on improvement priorities. Test different ways of communicating results to staff, leadership, and patients. Increase alignment of personnel policies and procedures with cultural competence goals. Add performance on cultural competence-related tasks (like data collection) to all job descriptions and evaluations. Develop and use a list of places to advertise new jobs that are likely to be seen by applicants who reflect the agency’s client population. Ideas for changes to test can also come from colleagues, and from outside resources. In the references slide at the end you will find several places to look for lists of changes to consider. See the references on slide 26

Putting it All Together: Testing and Implementation

General Cultural Competence Resources A Guide to Addressing Cultural Competence as a Quality Improvement Issue in HIV Care http://www.nationalqualitycenter.org/home/quality-improvement-resources/conducting-quality-improvement-activities.cfm/15189 Cultural Competence Resources for Healthcare Providers http://www.hrsa.gov/servicedelivery/default.htm Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile http://www.hrsa.gov/culturalcompetence/indicators/ AIDS Education and Training Centers, Guiding Principles for Cultural Competency http://www.aidsetc.org Now that we have gone over why you should use quality improvement to address cultural competence, how it can be used and how you can tell if using QI to improve cultural competence has been successful, we would like to give you some additional resources. You can look at these resources for other ideas on how to improve cultural competence and decrease disparities at your site. The last resource is a companion to this module, and you can find it on the NQC website.

References from Slide 9 1. Losina E, Schackman R, Sadownik S, et al. Disparities in survival attributable to suboptimal HIV care in the US: Influence of gender and race/ethnicity [abstract 142]. Presented at: 14th Conference on Retroviruses and Opportunistic Infections; February 25-28, 2007; Los Angeles, California. 2. Wilson Lucy, Korthuis P, Conviser R, et al. Rural Versus Urban HIV/AIDS Clinical Outcomes: A Multi-state Perspective [abstract 974]. Presented at: 14th Conference on Retroviruses and Opportunistic Infections; February 26, 2007; Los Angeles, California. 3. Hartzell J, Spooner K, Howard R et al. Race and mental health diagnosis are risk factors for Highly Active Antiretroviral Therapy failure in military cohort despite equal access to care. Journal of Acquired Immune Deficiency Syndrome. 2007; 44(4): 411-416.

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