Cultural and Linguistic Competencies: Assessment Tools and performance measurements

ASSESSMENT TOOLS AND PERFORMANCE MEASUREMENT
Research suggests a probable link between health and health care disparities and the need for improved cultural and linguistic competency in the provision of health care. Because of these findings, instruments for assessing cultural and linguistic competency at the individual and organizational levels have proliferated over recent years. This compilation of assessment tools and performance measures highlights site-specific and population-specific tools including step-by-step guides and participatory and multiple-method approaches for assessing individuals and organizations.

? Andrulis D, Delbanco R, Avakian L, Shaw-Taylor Y. Conducting a cultural competency self-assessment. 2000. Available at: http://www.consumerstar.org/pubs/Culturalcompselfassess.pdf. Accessed December 19, 2005.

This cultural competency assessment tool is one of the most cited instruments in the cultural competency literature. The packet of information walks the assessor through the assessment steps, provides sample questions for one-on-one interviews, includes a questionnaire that relates to three levels of cultural competency (i.e., individual, organizational and community) and provides recommendations for how to use assessment results.
American Hospital Association. Strategies for leadership: does your hospital reflect the community it serves? A diversity and cultural proficiency tool for leaders. Washington: DC: American Hospital Association; 2004. Available at: http://www.consumerstar.org/pubs/AHAassessment.pdf. Accessed December 20, 2005.

This short assessment was developed as a starting point in evaluating the diversity and cultural proficiency of health care organizations and identifying what activities and practices are in place or need to be implemented. The tool assesses at the levels of community, patient care, workforce development and organizational leadership. The document contains suggestions for using the tool to raise awareness in the organization and case studies of successful diversity and cultural proficiency programs from hospitals around the country.
Blank RM, Dabady M, Citro CF. Measuring Racial Discrimination: Panel on Methods for Assessing Discrimination. Washington, DC: National Academies Press; 2004. Available at: http://www.nap.edu/books/0309091268/html/. Accessed January 4, 2006.

This book discusses the findings of an expert panel convened to consider how best to measure discrimination. The book defines racial discrimination; assesses current methodologies for measuring discrimination (e.g., controlled laboratory experiments and field experiments, analysis of observational data and natural experiments, measures of reported perceptions and experiences of discrimination from surveys and administrative records) and identifies and makes recommendations for new, low-cost approaches (e.g., longitudinal interdisciplinary methods, augmenting current data collection).
Doorenbos AZ, Meyers Shim S, Benkert R, Borse NN. Psychometric evaluation of the cultural competence assessment instrument among healthcare providers. Nursing Research [serial online]. 2005;54(5):324-331. Available at: http://www.nursing-research-editor.com/authors/OMR/6/OMRManuscript.pdf. Accessed May 18, 2007.

This article briefly reviews the Cultural Competence Assessment instrument (CCA) and the extent to which this instrument appropriately measures the cultural competency of health care providers. Using hospice providers and health care providers in non-hospice settings, the authors tested the reliability of the CCA (i.e., whether or not the CCA consistently measured the cultural competency of the providers). Their findings confirmed the potential of the CCA as an instrument for measuring provider cultural competence and its usefulness to future research studies and intervention approaches.
Goode TD. Promoting cultural and linguistic competency: self-assessment checklist for personnel providing primary health care services. Maryland: Georgetown University Center for Child and Human Development. 2004. Available at: http://www11.georgetown.edu/research/gucchd/nccc/documents/Checklist%20PHC.pdf. January 10, 2006.

This brief cultural competency self-assessment tool is frequently cited in the assessment literature. Multiple variations of the tool are available for different settings (i.e., primary care service setting, early childhood setting, service setting for families with special health needs). Each variation asks the same questions, but uses terms appropriate to the setting. The assessment asks respondents to evaluate the physical environment in which they work, the materials and resources with which they work, their communication style and their values and attitudes.
Kairys JA, Orzano J, Gregory P, Stroebel C, DiCicco-Bloom B, Roemheld-Hamm B, Kobylarz FA, Scott JG, Coppola L, Crabtree BF. Assessing diversity and quality in primary care through the multi-method assessment process (MAP). Quality Management in Health Care. Summer 2002;10(4):1-14.

In this article, the authors argue that the multi-method assessment process (MAP), a comprehensive quality improvement assessment technique, can provide a systematic way to understand disparities in relation to diversity, cultural competence and quality improvement in clinical practice. MAP data are derived primarily from direct observation, interviews, document review, family medical histories and surveys. The authors encourage data collection in the following domains: 1) values/attitudes; 2) cultural sensitivity; 3) communication; 4) policies and procedures; 5) training and staff development; 6) facility characteristics; 7) intervention and treatment model features; 8) family and community participation and 9) monitoring, evaluation and research. Limitations of MAP include: 1) intensity of data collection and 2) difficult of analysis.
The Lewin Group, Inc. Indicators of cultural competence in health care delivery organizations: an organizational cultural competence assessment profile. Washington, D.C.: Health Resources and Services Administration, U.S. Department of Health and Human Services; 2002. Available at: http://www.hrsa.gov/culturalcompetence/indicators/. Accessed December 29, 2005.

The assessment profile described in this article is an analytic and organizing framework that can be used as a tool for examining, demonstrating and documenting cultural competence in organizations involved in direct health care delivery, especially those that are community-oriented. The framework is based on a synthesis of 120 published and unpublished literature sources given in the document cited immediately below (Health Resources and Services Administration study on measuring cultural competency in health care delivery settings). The profile has three focus areas: 1) domains of cultural competence; 2) focus areas within domains and 3) structure, process and outcome indicators related to focus areas. Domains include: organizational values, governance, planning, monitoring and evaluation, communication, staff development, organizational infrastructure and services/interventions.
The Lewin Group, Inc. Health Resources and Services Administration study on measuring cultural competency in health care delivery settings. Washington, DC: Health Resources and Services Administration, U.S. Department of Health and Human Services; 2001. Available at: http://www.hrsa.gov/culturalcompetence/measures/. Accessed December 29, 2005.

This comprehensive review of the cultural competency literature is an outgrowth of a Health Resources and Services Administration project to contribute to an understanding of how cultural competency can be measured and advance the capacity of organizations to carry out such measurement. The literature review provides the basis for the project’s objectives: 1) to develop a conceptual framework for measuring cultural competence in health care settings, 2) to identify specific indicators and measures for assessing cultural competence in health care and 3) to assess the feasibility and practical application of these measures.
? Mason JL. Cultural competence self-assessment questionnaire: A manual for users. Portland, OR: Research and Training Center on Family Support and Children’s Mental Health, Portland State University; 1995. Available at: http://www.rtc.pdx.edu/PDF/pbCultCompSelfAssessQuest.pdf. Accessed May 20, 2007.

This frequently cited organizational cultural competence self-assessment tool includes direct service provider and administrative staff assessments and a step-by-step manual for administering the questionnaire.
National Center for Cultural Competence. A guide for using the cultural and linguistic competence policy assessment instrument. Washington, DC: Georgetown University; 2006. Available at: http://www.clcpa.info/documents/CLCPA_guide.pdf Accessed May 18, 2007.

This guide provides a systematic process to plan for and assess organizational cultural and linguistic competency, specifically, attitudes and practices of personnel and program structures and policies. The guide helps organizations to engage in a strengths-based approach to assessment and disseminate results in a non-judgmental way.
National Technical Assistance Center for State Mental Health Planning (NTAC). Cultural competency: Measurement as a strategy for moving knowledge into practice in state mental health systems. Alexandria, VA: NTAC; 2004. Available at: http://www.nasmhpd.org/general_files/publications/cult%20comp.pdf. Accessed May 18, 2007.

This report advocates that cultural competence must be integrated into and permeate the entire mental health system. It outlines the rationale for cultural competence, approaches to implementation, measurement of cultural competency as a strategy and steps that can be taken to move research into practice.
Research & Training Center for Children’s Mental Health. Organizational cultural competence: A review of assessment protocols. Tampa, FL: University of South Florida; 2006. Available at: http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/protocol/CultCompProtocol.pdf Accessed May 21, 2007.

This monograph presents the findings from a review of cultural competence assessment tools designed for use at the organizational level. The findings contribute to the goal of developing cultural competence in systems of care wherein participating organizations must support the delivery of culturally competent services and develop collaborative relationships with diverse communities. A conceptual model for organizational cultural competence was informed by and guided this review, illustrating the relationships between the community’s populations, organizational structures and processes, direct service structures and processes, and the overall community context.
Siegel C, Davis-Chamber E, Haugland G, Bank R, Aponte C, McCombs H. Performance measures of cultural competency in mental health organizations. Administration and Policy in Mental Health, November 2000;28(2):91-106.

This article describes a multi-level framework for assessing the cultural competency of mental health systems. A steering committee reviewed more than 20 reports and papers on cultural competency developed by state/federal agencies and multicultural focus groups. Based upon the review, the steering committee synthesized the data into six domains: 1) needs assessment, 2) information exchange, 3) services, 4) human resources, 5) policies and procedures, and 6) outcomes. These domains help assess cultural competency within three different organizational structures: administrative, provider network and individual caregiver. Within each domain, there are factors, indicators and measures that can be applied to assess cultural competency. The steering committee identified a total of 117 cultural competency indicators and 173 cultural competency measures.
Siegel C, Haugland G, Davis-Chambers E. Cultural competency methodological and data strategies to assess the quality of services in mental health systems of care: A project to select and benchmark performance measures of cultural competency. New York: Nathan Kline Institute for Psychiatric Research; 2002. Available at: http://csipmh.rfmh.org/other_cc.pdf. Accessed May 18, 2007.

This report includes recommendations and benchmark performance measures for mental health systems to increase their responsiveness to the needs of multicultural populations. A conceptual framework identifies five domains in which the performance measures can be applied to achieve good outcomes: 1) needs assessment, 2) information exchange, 3) services, 4) human resources and 5) policies and plans. The framework also highlights three organizational levels that need to be involved in the delivery of culturally competent services: 1) administrative, 2) service delivery and 3) individual.

Siegel C, Haugland G, Davis-Chambers E. Performance measures and their benchmarks for assessing organizational cultural competency in behavioral health care service delivery. Administration and Policy in Mental Health. 2003;31(2):141-170.

This article outlines the second phase of a two-phase effort to identify performance measures to assess organizational progress toward cultural competency. The following benchmarks emerged as indicators of a commitment to cultural competence at the administrative, service and individual levels, respectively: 1) an organizational cultural competency plan, an advisory committee, a person responsible for cultural competency, budget line items and a governing board; 2) telephone instruction available in languages other than English, language assistance available at first contact as well as other points of contact, bilingual staff, educational and other materials in non-English languages and information on rights and grievances in non-English languages and 3) knowledge of target populations and the cultural needs of patients, linguistic capacity, cultural competency training and education, equitable recruitment and hiring practices, and consumer education about outcomes.

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