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

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Appendix E[INSERT NAME OF STUDY OR DATA COLLECTION EFFORT]CLIENT SERVICES QUESTIONNAIREThank you for taking the time to complete this questionnaire. The purpose of this study is tocollect information on health care policies and practices that extend medical support or servicesto meet the needs of members of diverse linguistic, national, or cultural backgrounds.Participation in this study does not require that your agency have any sort of policies in placethat address the particular needs of certain cultural groups. There are no expectations orjudgments about services that are, or are not, offered by your agency. In the event that certainagencies report unique policies or practices that exceed current standards of care for diversegroups, prior permission will be requested from the participating agency to highlight in futurepublications information provided from those responses only. Anonymity is assured; data willbe reported as summaries without individual or agency identification. A unique benefit of yourparticipation in this study is that your agency will receive a copy of actual responses submittedby your staff that may be useful to your health agency in identifying and monitoring CLASprovision for quality improvement and other reporting purposes.Although the focus of this questionnaire is on health care services provided to members ofdiverse cultural groups, the form is divided into four sections that cover specific topics withinthe broader inquiry. Depending on the structure of your agency, it may be appropriate fordifferent individuals in your agency to complete certain sections of the questionnaire based ontheir roles, responsibilities, and knowledge—thereby greatly reducing individual time and effort.You are encouraged to distribute certain sections or questions to the appropriate colleague inyour agency in order to complete as many questions as you can. Some questions call for yourbest single answer. Questions that call for multiple responses are labeled “Mark All ThatApply.”RETURN INSTRUCTIONSThank you again for your participation. There are two options for returning your completed questionnaire:1. Mail the completed form using the enclosed pre-paid envelope.If you have misplaced the envelope, please send the completed form to:Complete as appropriate2. Submit your completed form by facsimile transmission to:Complete as appropriatePaperwork Reduction Act StatementA federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless itdisplays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to vary from20-30 minutes with an average of .5 minutes per response, including time for reviewing instructions, searching existing datasources, gathering and maintaining the necessary data, and completing and reviewing the collection of information.COSMOS Corporation, December 2003
A. QUALITY MONITORING AND IMPROVEMENT (QI)The following questions are about your basic systems for tracking data about your clients andservices you provide, and how these data are used in planning, promoting, and evaluating servicesthat address the specific needs of culturally and linguistically diverse groups represented by yourclients. These would include internal routine information systems and quality monitoring andimprovement procedures.1. Does your agency have a formal plan for collecting information on the quality of culturally andlinguistically appropriate services provided to clients?~ Yes, a plan developed by our local agency~ Yes, a plan developed by the local board of health or other governing body~ Yes, a plan developed by the State~ No~ Don’t know2. Which of the following activities are used to collect information on the quality of culturally andlinguistically appropriate services?MARK ALL THAT APPLY~ Collection, review, and analysis of quality outcomes data~ Client satisfaction surveys~ Grievance and complaint tracking~ Chart reviews and audits~ Client focus groups~ Other, please specify _______________________________________~ Don’t know~ None of the above3. For what purpose(s) does your agency collect this information?MARK ALL THAT APPLY~ Federal reporting requirement~ State reporting requirement~ Local board of health or other governing body reporting requirement~ To improve services~ Other, please specify _______________________________________COSMOS Corporation, December 2003 2
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Developing a Self-Assessment Toolfo
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ContentsChaptersPage1. Introduction
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Chapter 1Introduction
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While many LPHAs currently provide
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LPHAs include: adult and child immu
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Professions Education Partnership A
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Chapter 2Methodology for Developing
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Public Health Practice Program Offi
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assess their own beliefs and have k
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communicate with, and clearly under
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2.1.6 Identifying Key Components of
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Given these persistent disparities
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(Exhibit 2-2, Continued)DOMAIN / KE
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limited to the actual clinical enco
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Chapter 3Project Results and Recomm
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local board of health. PEP and PAG
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numerous promising CLAS practices a
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References
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Becker, M.H., and L.A. Maiman, “S
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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
Page 81 and 82: 1c. Please indicate for which categ
Page 83 and 84: 6. Please indicate for which catego
Page 85 and 86: 10. Which of the following topical
Page 87 and 88: 17. Which of the following benefits
Page 89 and 90: 4. Which of the following strategie
Page 91: Appendix EClient Services Questionn
Page 95 and 96: 6b.Which of the following community
Page 97 and 98: 3. Please report or estimate what p
Page 99 and 100: 3. Which of the following practices
Page 101 and 102: Oral Interpretation Services10. Whi
Page 103 and 104: 16. At which of the following key e
Page 105 and 106: 3. Which of the following kinds of
Page 107 and 108: Appendix FPilot Test Response Form
Page 109 and 110: 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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