Presentation on theme: "Is Hospital Cultural Competency Associated with Better HCAHPS scores?"— Presentation transcript:
1Is Hospital Cultural Competency Associated with Better HCAHPS scores? Robert Weech-Maldonado, Ph.D.Department of Health Services AdministrationUniversity of Alabama at Birmingham1
2Collaborators Marc N. Elliott, RAND Rohit Pradhan, University of Arkansas Medical SciencesCameron Schiller, ConsultantAllyson Hall, University of FloridaJanice Dreachslin, Penn State UniversityRon D. Hays, UCLA
3Disparities in CareIOM (2003) report “Unequal Treatment” documented disparities in careDisparities in patient experiences with careNational Consumer Assessments of Healthcare Providers and Systems (CAHPS) Benchmarking DatabaseRacial/ethnic minorities, especially non-English speakers have worse reports of care in Medicaid managed care (Weech-Maldonado et al., 2001, 2003, 2004)Diversity and health care deliveryCommunication and other institutional barriers as a result of cultural and language differencesCultural competency one of the strategies to address health disparities
4Cultural Competency and Health Disparities DiversePopulationsCulturalCompetencyAppropriateServices forMinorityGroupMembersImprovedOutcomesFor MinorityGroupMembersReduction ofHealthDisparities+Brach and Fraser (2000)
5What Is Cultural Competency? The National Quality Forum (NQF) (2008. p3) defines cultural competency as the:“Ongoing capacity of healthcare systems, organizations, and professionals to provide for diverse patient populations high-quality care that is safe, patient and family centered, evidence based, and equitable.”And states that cultural competency is achieved through:“Policies, learning processes, and structures by which organizations and individuals develop the attitudes, behaviors, and systems that are needed for effective cross-cultural interactions”
6Assessments of Cultural Competency LevelsOrganizationalCultural Competency Assessment Tool for Hospitals (CCATH)ProviderPatientConsumer Assessments of Healthcare Providers and Systems (CAHPS ®)
7Cultural Competency Assessment Tool for Hospitals (CCATH) Systems approachUS Department of Health and Human Services Office of Minority Health (2001, 2013)Cultural and linguistic appropriate services (CLAS) standardsNational Quality Forum (NQF) (2008)A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency
8NQF Comprehensive Framework LeadershipIntegration into Management Systems and OperationsWorkforce Diversity and TrainingCommunity EngagementPatient-Provider CommunicationCare Delivery and Supporting Mechanisms
9Development of CCATHAssess appropriateness of existing survey instruments for the CCATHDesign the CCATHPilot test and revise the CCATHQualitative testing (focus groups and cognitive interviews) of revised CCATH survey instrumentCCATH field test and psychometric testing
10NQF Domain CLAS Standard # Items Alpha Mean CCATH Composite#ItemsAlphaMeanLeadership8, 14Leadership and Strategic Planning60.7935.8Integration into Management Systems and Operations10Data Collection on Inpatient Population20.7087.111Data Collection on Service Area70.8460.59Performance Management Systems and QI30.7833.3Workforce Diversity and TrainingHuman Resources Benefits80.6662.23, 13Diversity Training0.6853.7Community Engagement12Community Representation40.2Patient-Provider Communication4Availability of Interpreter Services0.8770.25,6Interpreter Services Policies0.6561.1Quality of Interpreter Services0.7558.1Translation of Written Materials0.8152.3Care Delivery1Clinical Cultural Competency Practices0.7681.4
11CCATH Composite Scales (Example of Survey Items) Leadership and strategic planning (mean=36)Does this hospital's statement of strategic goals include...Specific language about recruitment of a culturally diverse work force?Specific language about retention of a culturally diverse work force?Specific language about the provision of culturally appropriate patient services?
12CCATH Composite Scales HR benefits (mean= 62)Formal mentoring programFlexible benefits such as domestic partner benefits, family illness, death, and personal leave policies that accommodate alternative definitions of familyDiversity training (mean= 54)Does this hospital have a formal and ongoing training program on cultural and language diversity?Check domains and meansDone
13CCATH Composite Scales Quality of interpreter services (mean= 58)Does the hospital require an assessment of... Interpreter accuracy and completeness?Translation of written materials (mean= 52)What types of written materials does this hospital routinely provide to in-patients in languages other than English? IF YES: In what languages are written materials translated? (Mark all that apply)Discharge planning instructionsMedication instructionsClinical cultural competency practices (mean= 81)Accommodate the ethnic/cultural dietary preferences of in-patients?Tailor patient education materials for different cultural and language groups?Check meansDone
14Conceptual Framework (Donabedian, 1988) Structure of Care Process of care OutcomesHospital’s Cultural CompetencyPatient Experiences with CarePatient Satisfaction and Other Outcomes of Care
15HypothesesHypothesis 1: Patients receiving care in hospitals with greater cultural competency will report better experiences with inpatient careHypothesis 2: The experiences of minority patients relative to non-Hispanic White English-speaking patients will be better at hospitals with higher levels of cultural competency than at hospitals with lower levels of cultural competency
16DataCCATH survey dataMail survey of California hospitalsOctober May 2007Total Design Method (Dillman, 1978)Response rate: 125 hospitals (37%)Respondents less likely to be part of a system (49% vs. 65%), but more likely to have a greater minority inpatient population (40% vs. 36%)Consumer Assessments of Healthcare Providers and Systems (CAHPS) Hospital Survey (HCAHPS)198 CA HospitalsMerged CCATH and HCAHPS data19,583 patients from 66 hospitals had both CCATH and HCAHPS data
17Dependent Variables-Hospital CAHPS Evaluations of Care 6 composites (based on 2-3 report items each):Communication with nursesStaff responsivenessCommunication with doctorsPain controlCommunication about medicationsDischarge informationTwo stand-alone report items assess physical environment (cleanliness and quietness)Two global items (recommendation of hospital to friends and family, and overall rating of hospital)All outcomes transformed to a possible range
18Independent VariableAverage Score for Cultural Competency (12 CCATH Domains):Clinical cultural competency practicesHR practicesDiversity trainingAvailability of interpreter servicesInterpreter services policiesQuality of interpreter servicesTranslation of written materialsLeadership and strategic planningRacial/ethnic assessments and QIData collection on inpatient populationData collection on service areaCommunity representation
19Control Variables Racial/ethnic and language subgroups White Non-English SpeakerHispanic English Survey, English at HomeHispanic English Survey, Spanish/Other Language at HomeHispanic Spanish SurveyBlack English at HomeAsian/Pacific Islander English at HomeAsian/Pacific Islander Other Language at HomeAmerican IndianMultiple RacesMissing Race/Ethnicity or Language at HomeCase Mix VariablesAgeEducationSelf-rated Health statusService line (medical, surgical, obstetrics)Age * Service lineER Admission source
20Analysis-Two Mixed Models Predicted overall HCAHPS scores from a hospital random effect, plus fixed effects for hospital’s degree of cultural competency, individual race/ethnicity/language, and case-mix variablesModel 2Adds a fixed effects interaction between hospital cultural competency and a patient racial/ethnic minority indicator
22STDV of Hospital-Level Random Effect Results (Model 1)HCAHPSEffect of 1 STDVCCATH ScoreSTDV of Hospital-Level Random EffectNurse Communication0.382.42***Staff Responsiveness0.103.37***Doctor Communication0.73*1.79***Clean Room-0.233.10***Quiet Room0.124.77***Pain Control0.112.10***Medications Communication-0.242.77***Discharge Information-0.553.29***Hospital Rating1.22***Hospital Recommendation1.55***3.44***Added to title. Column headings: Updated table using ccath-hcahps xls
23Results (Model 2) HCAHPS Effect of 1 STDV CCATH Score* Minority IndicatorSTDV of Hospital-Level Random EffectNurse Communication0.88*2.42***Staff Responsiveness1.32**2.88***Doctor Communication-0.031.78***Clean Room-.033.09***Quiet Room1.04*4.73***Pain Control1.51***2.1***Medication Communication0.412.76***Discharge Information-0.161.34***Hospital Rating0.252.89***Hospital Recommendation-0.153.44***
24ResultsModel 1 shows that cultural competency was positively associated with doctor communication, hospital rating, and hospital recommendation. These are considered medium size effectsModel 2 provides evidence of greater relative benefits for those who were not English-speaking non-Hispanic Whites for 4 of the 10 measures examined: nurse communication, staff responsiveness, quiet room, and pain control. These are considered medium size effects, except for quiet room which is smallAdded to Title; added 1st bullet; edited 2nd bullet: Modified title and updated bullet on Model 3 using ccath-hcahps xls
25ConclusionsCultural competency may both improve patient’s overall hospital experiences and doctor communication in generalThe impact of cultural competency on dimensions of care related to interactions with non-physician hospital staff, is greater among minority patients
26Policy/Managerial Implications Business case for cultural competencyBecause cultural competency appears to be associated with better patient experiences, there may be a market incentive for the implementation of such practicesHospital Compare and HCAHPSBeginning in 2013, CMS will incorporate HCAHPS into value-based purchasing program providing direct financial incentivesQI activities tied to cultural competency efforts show notable promise for improving HCAHPS scores, but particular promise for hospitals with significant racial/ethnic/language minority patient populations.
27Strategic Diversity Leadership “Diversity leadership is a differentiation strategy that is responsive to demographic shifts and changing social attitudes among both the patients and the workforce” (Dreachslin, 1999:428)Diversity leadership is essential for cultural competencyDiversity leadership is a strategy; as such it is driven by leadership.And it cannot be in place unless hospital’s leaders believe that the organization must be responsive to patient demographics and recruit and retain a workforce that reflects the community it serves.In short, leaders must have a strong Diversity Sensitive Orientation.
28Four Cornerstones: Strategic Diversity Leadership Strategic PlanStrategic plan goals for diversity in two areas:Recruitment and Retention of a Culturally Diverse WorkforceProvision of Culturally and Linguistically Appropriate Patient CarePerformance MetricsRoutine assessment of diversity goal achievement as part of strategic planningAccountabilityDedicated person, office or committee assigned responsibility to promotethe hospital’s cultural diversity goalsCommunity InvolvementAnnually report to the community about the hospital’s performance in meeting the cultural and language needs of the service area.The 4 practices on this slide predict CLAS adherence.This study offers more support for a C-Suite driven strategic approach to diversity management!
29Examples of NQF-Endorsed Preferred Practices Workforce diversity and trainingImplement training that builds a workforce that is able to address the cultural needs of patients and provide appropriate and effective services as required by federal, state, and local laws, regulations, and organizational policiesPatient-provider communicationOffer and provide language access resources in the patient’s primary written and spoken language at no cost, at all points of contact, and in a timely manner during all hours of operation, and provide both verbal offers and written notices informing patients of their right to receive language assistance services free of chargeCare delivery and supporting mechanismsAdapt the physical environment where the healthcare is being delivered to represent the culture of the populations who access their healthcare in that environmentIn the next slides we provide examples of preferred practices from the NQF endorsed framework.
30Cultural Competency and Quality Improvement Assess baseline performanceUse organizational instrument, such as CCATHAnalyze HCAHPS by race/ethnicityIdentify strengths and weaknessesConduct focus groups for further insights on survey findingsIdentify action plan to address gapsRefer to NQF preferred practices for cultural competencyImplement action planEvaluate effectiveness of action planStrive for continuous improvementYou may ask…how can we use the results of this survey in quality improvement? We suggest following a quality improvement process. This starts by assessing baseline performance. Examine your scores by topic area as well as for individual items. This will help you identify the areas of strengths and weaknesses. It is important to analyze racial/ethnic and language differences. For this it may be necessary to oversample.If possible, conduct focus groups to obtain qualitative data that may provide further insights into the survey data.Identify and implement an action plan to address your gapsEvaluate the effectiveness of the action plan by administering the CAHPS CC survey.Ultimately strive for continuous improvement
31References (CCATH)Weech-Maldonado, R., Ellliott, M.N., Pradhan, R., Schiller, C., Hall, A., and Hays, R.D. Can Hospital Cultural Competency Reduce Disparities in Patient Experiences with Care? Medical Care 50(9 Suppl 2): S48-55medicalcare/Fulltext/2012/11001/Can_Hospital_Cultural_Competency _Reduce.10.aspxWeech-Maldonado, R., Elliott, M.N., Pradhan, R. Schiller, C., Dreachslin, J., and Hays, R.D. Moving towards Culturally Competent Health Systems: Organizational and Market Factors Social Science and Medicine, 75(5):Weech-Maldonado, R., Dreachslin, J., Brown, J., Pradhan, R., Rubin, K.L., Schiller, C., and Hays, R.D. Cultural Competency Assessment Tool for Hospitals (CCATH): Evaluating Hospitals' Adherence to the CLAS Standards Health Care Management Review, 37(1):
32Resources Cultural Competency Assessment Tool for Hospitals (CCATH) ???????????National Quality Forum (A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency)
33AcknowledgementsCommonwealth FundDHHS’s Office of Minority Health