Developing a Self-Assessment Toolfor Culturally - Office of Minority ...

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Exhibit 2-2CONCEPTUAL FRAMEWORK FOR ASSESSING CLAS IN LPHAsDOMAIN / KEY ELEMENT1. Organizational GovernanceA. Governing boards,committees, and positionsB. Organizational StructureVARIABLESA. Local Board of Health subcommittee on CLASPermanent advisory committeeCommittee recruitment strategiesCommittee racial/ethnic compositionCommittee diversity other than race/ethnicityInternal CLAS working groupStaff position specifically for CLAS coordinationFrequency of meetingsCommittee’s role in CLASB. Formal grievance procedureClient population size2. CLAS Plans and PoliciesA. CLAS planning A. Formal quality improvement plan for culturally and linguisticallydiverse clientsInternal CLAS planning and working groupsStaff and community inputMission statement addresses CLASCommittee roles related to CLASB. CLAS policies B. CLAS training program reviewTranslation products reviewTargets for translated materialsDescription of translationPolicies governing written translationReasons translation policies existsReasons translation policies do not existPolicies governing interpretation servicesReasons interpretation policies existsReasons interpretation policies do not existFormal grievance process for CLAS-related concernsDocumented policy for interpretersFormal staff diversity planFormal diversity training programStaff position for CLAS coordinationStaff and community inputInternal communication strategies for CLAS policies3. Culturally Inclusive HealthCare Environment andPracticesA. Assessment and TreatmentB. Materials and EnvironmentA. Cultural differences and preferences consideredFamily members and preferences consulted during diagnosis andtreatmentCulturally specific healers and physicians consultedUtilize alternative and complementary treatmentsB. Cultural differences and preferences consideredFamily members and preferences consulted during diagnosis andtreatmentCulturally specific healers and physicians consultedVarious culturally responsive strategies implementedCharacteristics of written materialsAlternative and complementary treatments available(Continued on next page)COSMOS Corporation, December 2003 2-11
(Exhibit 2-2, Continued)DOMAIN / KEY ELEMENT4. CLAS Quality Monitoring andImprovement (QMI)A. Tracking systemB. Needs assessment (NA) andevaluation5. Management InformationSystems (MIS)A. ClientsB. Staff6. Staffing PatternsA. Staff diversityB. Staff recruitment,retainment, and promotionVARIABLESA. Quality improvement activities conductedMultiple methods for monitoring CLAS qualityCLAS accountability for providersQuality of care data collectionUses of CLAS-specific dataUses of quality improvement dataLink client demographic and outcome dataLink client and provider dataLink client and (other) staff dataB. Routine assessments of services, procedures, and policiesFrequency of needs assessmentsTypes of community/client groups that participate in needsassessmentClient/community needs assessment specifically for CLASData sources for client/community CLAS needs assessmentTraining program evaluated for effectivenessState and local support for quality improvement activitiesTypes of staff who participate in needs assessmentTypes of agency support for quality improvement and needsassessment activitiesA. Clients’ primary language recordedReasons clients’ language not recordedClients’ race/ethnicity recordedReasons clients’ race/ethnicity not recordedRacial/ethnic composition of client populationClients’ primary languages other than EnglishUses of CLAS-specific dataPercentage of clients who speak non-English primary languageB. Staff linguistic capability recordedMethod of determining staff linguistic capabilityStaff race/ethnicity recordedReasons staff race/ethnicity not recordedTypes of staff for whom race/ethnicity is recordedA. Racial/ethnic composition of staffPercentage of bi- or multi-lingual staffInformation on the diversity of staff and services available to thecommunityB. Staff diversity planTypes of staff covered in agency diversity planStrategies to recruit, retain, and promote diverse staffResources utilized to recruit diverse staffIncentives for multi-lingual providersOrganizational support for diverse staff and developmentStaff position funded for CLAS coordination(Continued on next page)COSMOS Corporation, December 2003 2-12
Page 1 and 2: Developing a Self-Assessment Toolfo
Page 3 and 4: ContentsChaptersPage1. Introduction
Page 5 and 6: Chapter 1Introduction
Page 7 and 8: While many LPHAs currently provide
Page 9 and 10: LPHAs include: adult and child immu
Page 11 and 12: Professions Education Partnership A
Page 13 and 14: Chapter 2Methodology for Developing
Page 15 and 16: Public Health Practice Program Offi
Page 17 and 18: assess their own beliefs and have k
Page 19 and 20: communicate with, and clearly under
Page 21 and 22: 2.1.6 Identifying Key Components of
Page 23: Given these persistent disparities
Page 27 and 28: limited to the actual clinical enco
Page 29 and 30: Chapter 3Project Results and Recomm
Page 31 and 32: local board of health. PEP and PAG
Page 33 and 34: numerous promising CLAS practices a
Page 35 and 36: References
Page 37 and 38: Becker, M.H., and L.A. Maiman, “S
Page 39 and 40: Frye, B., “Health Care Decision M
Page 41 and 42: Marin, G., “Defining Culturally A
Page 43 and 44: Perkins, Jane, “Overcoming Langua
Page 45 and 46: U.S. Bureau of the Census, “Censu
Page 47 and 48: Appendix AMembership Lists of the P
Page 49 and 50: Appendix A-1Developing a Self-Asses
Page 51 and 52: Appendix A-2Developing a Self-Asses
Page 53 and 54: Appendix B-1Overview of Eight CLAS
Page 55 and 56: Domain 3: Culturally Inclusive Heal
Page 57 and 58: understanding of diversity issues i
Page 59 and 60: Appendix B-2Conceptual Framework fo
Page 61 and 62: Appendix CLPHA Director or Designee
Page 63 and 64: Pre-Interview Script for LPHA Direc
Page 65 and 66: 3b. Which of the following are refl
Page 67 and 68: 6. Does your agency have a formal p
Page 69 and 70: 10. Which of the following describe
Page 71 and 72: Post-Interview Script for LPHA Dire
Page 73 and 74: Appendix DStaffing Questionnaire
Page 75 and 76:
A. QUALITY MONITORING AND IMPROVEME
Page 77 and 78:
B. MANAGEMENT INFORMATION SYSTEMS (
Page 79 and 80:
7. Please indicate, if you know, th
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1c. Please indicate for which categ
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6. Please indicate for which catego
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10. Which of the following topical
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17. Which of the following benefits
Page 89 and 90:
4. Which of the following strategie
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Appendix EClient Services Questionn
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A. QUALITY MONITORING AND IMPROVEME
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6b.Which of the following community
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3. Please report or estimate what p
Page 99 and 100:
3. Which of the following practices
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Oral Interpretation Services10. Whi
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16. At which of the following key e
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3. Which of the following kinds of
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Appendix FPilot Test Response Form
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RESPONDENT EVALUATIONOF THE QUESTIO
Page 111 and 112:
Appendix GCLAS in MCOs Study Data C
Page 113 and 114:
position, as titles will likely var
Page 115 and 116:
complex and uncertain at the time t
Page 117 and 118:
1. Incorporate a confirmation pre-c
Page 119 and 120:
Exhibit 2DATA COLLECTION PROCESSSen
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