Quality Improvement Organizations (QIOs) and CLAS/Cultural Competency Ann Kenny, MPH, BSN, RN Project Director, SRA International, Inc. May 22, 2009

2 Institute of Medicine 2002 Report – Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care Potential sources of disparities Patients: minority patients are more likely to refuse recommended services, delay seeking care, and not follow physician orders Health care system: places time constraints on physicians and restricts time to overcome language and cultural barriers Providers: more likely to rely on shortcuts due to time constraints Patients: minorities have more difficulty trusting their health care providers

3 Legislation, Accreditation, & Regulation Dark Blue denotes legislation requiring (WA, CA, NJ, NM) or strongly recommending (MD) cultural competence training, which was signed into law. Purple denotes legislation which has been referred to committee and is currently under consideration. Royal Blue denotes legislation which died in committee or was vetoed. NOTE: Cultural competency legislation is also being considered at the Federal level. Bill S.1576 has been referred to the Committee on Health, Education, Labor, and Pensions.

4 8th SOW: August Task 1: Assisting Providers in Developing the Capacity for Achieving Excellence (TOTAL) 1a: Nursing Home 1b: Home Health 1c1: Hospital 1c2: Critical Access Hospital/Rural PPS Hospital 1d1: Physician Practice IPG 1d2: Physician Practice/Underserved Populations 1d3: Physician Practice/Pharmacy: Part D Benefit

5 Task 1d2: Physician Practices/Underserved Populations QIO promotes adoption of CLAS Standards and completion of cultural competency requirements through OMH e-learning program. QIO shall work with the IPG practice sites to assess adoption of the CLAS standards through a practice- site self assessment. QIO shall provide assistance to the practice sites in meeting or exceeding at least one of the CLAS Standards 4-7.

6 Participants can: Watch streaming video case studies or view transcripts Answer pre- and posttests that provide immediate feedback and review missed questions Receive instant online grading and CME/CEU certification at no cost View other providers comments Participate in self-assessment exercises A Physicians Practical Guide to Culturally Competent Care: The Cultural Competency Curriculum Modules (CCCMs) u Released in December 2004 u Designed to equip providers with cultural and linguistic competencies required to improve quality of care u Accredited for physicians, physicians assistants, and nurse practitioners

7 CCCM User Statistics Over 32,000 registered users 50% of registered users are MDs 56% of registered users are female 66% of users are White Nearly 1/3 of users are between the ages of Top specialties of participants are: family medicine, internal medicine, pediatrics, obstetrics/gynecology 130,000 credits awarded to participants 59% of certificates awarded are CME certificates (physicians) 17% of certificates awarded are Statements of Participation (any participant for whom the course is not specifically accredited) *As of

8 CCCM QIO User Statistics

9 CCCM QIO User Statistics (contd.)

10 CCCM QIO User Statistics (contd.)

11 Two-Year Evaluation Report of the CCCMs Evaluation Methodology Quantitative Qualitative Pre- and Posttest Scores Course Evaluation Questionnaire Take a Moment Questions Focus Groups Web-captured Comments Conducted in December 2006, two years after launch Study Population: 2,213 participants total, 50.56% (n=1,119) affiliated with a QIO 42% Female, 58% Male 60% White non-Hispanic, 13% Asian, 11% Black, 8% Hispanic, 6% Other, 1% AI/AN, 1% NHOPI Participant practice settings include: Hospitals, Clinics, Private Practice, Community Health Centers Common specialties: Family Practice, Internal Medicine, Pediatrics

12 Evaluation Objectives Explore the extent to which completion of the curriculum results in physician self-reported improvements in: 1) Knowledge of culturally competent care models, principles, and theories 2) Attitudes toward diverse patient types 3) Utilization of interpreter services and translated materials 4) Practice habits 5) Educational/communication practices in direct physician-patient interactions

13 Objective 1: Increased knowledge of culturally competent care models, principles, and theories Physicians scored higher on posttests than on pretests Score increases ranged from 1.01 (approx. 1 point) to 2.01 (approx. 2 points) Pretest scores ranged from 73% to 75% Posttest scores ranged from 83% to 94%

14 Objective 2: Change in attitudes toward diverse patient types 73.8% of participants sympathized with American Indian patient featured in case study one I feel a lot of sympathy for Mrs. Williams. I believe Dr. Brown means well, but he comes across as arrogant and uncaring. 27.7% of participants directly expressed support for the patient in case study two and were concerned about the quality of care she received The office staff are providing very substandard care by their underlying stereotyping.

15 Objective 3: Change in use of interpreter services and translated materials Increased awareness regarding current interpreter practices One thing that impacted me was not using family members as interpreters. A lot of times Im forced to do that or it seems like the best method at the time, but now I can understand how certain issues may be sensitive to people, even if I dont think they are sensitive issues. I really started to realize that having an interpreter is a good practice builder. It has been a boon to my practice. I learned a lot about dealing with interpreters. Recently, I had an interpreter who just took off talking to the patient because I did not tell him I wanted to be in charge of the conversation. Now I am a lot more in-tune and aware.

16 Objective 4: Improved practice habits *Data from focus groups (N=53) Level of Agreement

17 Objective 4: Improved practice habits for QIO participants Since completing the CCCMs, I believe I have actually changed my practice habits to reflect what I learned in the course. Level of Agreement

18 Objective 5: Enhanced educational/communication practices in direct physician-patient interactions I have applied at least one of the communication techniques that I saw in the vignettes in my daily practice. Level of Agreement *Data from focus groups (N=53) N

19 Objective 5: Enhanced educational/ communication practices in direct physician-patient interactions for QIO participants Level of Agreement I have applied at least one of the culturally competent communication techniques that I saw in the vignettes in my daily practice.

20 QIO Survey Feedback The Facilitators Guide was extremely helpful. It is one of the most comprehensive, step-by-step guides for facilitating a curriculum that Ive ever seen. Participant interaction flows pretty naturally from the content, especially the video vignettes. The video vignettes are great. Participants frequently cite them as the best part of the course, and they definitely promote the most discussion. Participants enjoyed having a hard copy of the certificate to take with them.

21 Summary of Findings Physicians enter CCCMs with a reasonable understanding of cultural competency, but show increased posttest scores and knowledge gain Curriculum participation renders a positive impact on practice behavior Increased sensitivity to cultural differences Took more time with patients Asked more patient-centered questions Course resulted in improved perceptions of medical interpreters Curriculum participation results in enhanced self- awareness of cultural competency concepts

22 For More Information, Contact: Ann Kenny, MPH, BSN, RN Project Director SRA International, Inc.