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Cultural responsiveness: a prescription for a better health system Lidia Horvat Policy & Strategy Unit, Quality, Safety & Patient Experience Branch Department.

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Presentation on theme: "Cultural responsiveness: a prescription for a better health system Lidia Horvat Policy & Strategy Unit, Quality, Safety & Patient Experience Branch Department."— Presentation transcript:

1 Cultural responsiveness: a prescription for a better health system Lidia Horvat Policy & Strategy Unit, Quality, Safety & Patient Experience Branch Department of Health, Victoria

2 Outline 1.Linking access, equity, quality and safety 2.Policy conceptualisation and implementation 3.Standards and performance measures 4.Achievements and promising practices 5.Emerging research initiatives

3 1. Linking access, equity, quality and safety Concretise the links between access & equity and quality & safety Align risk management, patient safety, quality improvement and cultural responsiveness Embed cultural responsiveness into core health service planning and implementation A whole-of-organisation approach Develop standards, measures and benchmarks to improve health services responsiveness to CALD issues.

4 1. Linking access, equity, quality and safety Health care disparities: the need for culturally responsive health care Links between culture, language and patient safety outcomes (Johnstone & Kanitsaki: 2006) Impact of culture and language on health disparities for diverse populations (Wilson-Stronks et. al: 2008, Betancourt et. al: 2003,) Mounting evidence of disparities in patient safety: that people from diverse backgrounds receive poorer quality health care than English speaking background patients, (Divi et. al, 2007, Suurmond et. al: 2010) A trajectory of accident opportunity and adverse events in their journey through the health system (Divi et. al, 2007).

5 1. Linking access, equity, quality and safety Context US hospitals pilot study: Divi et. al 2007 Six Joint Commission accredited hospitals Adverse event data collected over 7 months in 2005 using National Quality Forum endorsed Patient Safety Event Taxonomy * LEP = Low English proficiency Results 49.1% of LEP patient adverse events involved some physical harm, compared with 29.5% of English speaking patients adverse events Of those adverse events resulting in physical harm: 46.8% of LEP patients had harm ranging from moderate temporary harm to death compared with 24.45 % of English speaking patients Overall Communication errors: 52.4% LEP patients 35.9% English speaking patients

6 1. Linking access, equity, quality and safety Research and evidence base - benefits Reducing health care disparities and increasing access to healthcare: Jacobs et. al. 2004, Le Sage 2006 Enhancing quality of care: Flores 2005, Karliner 2007 Reduction of errors (clinical or interpreter): Cohen et. al.2005,Flores 2006, Gany et. al. 2007 Improving patient health outcomes: Cohen et. al. 2005, Divi et. al. 2007, Flores 2005 Reducing cost of services: Bernstein et. Al. 2002, Graham et. al. 2008, Jacobs et. Al. 2007 Enhancing patient-provider communication: Bischoff et. al. 2008, Hablamos Juntos 2007b, Schenker et. Al. 2007, Ramirez et, al. 2008 Risk management/ legal liability: Australian Charter of Healthcare Rights in Victoria, Charter of Human Rights and Responsibilities Act, Victoria.

7 2. Policy conceptualisation and implementation Cultural responsiveness : health care services that are respectful of, and relevant to, the health beliefs, health practices, culture and linguistic needs of diverse consumer/patient populations and communities. Describes the capacity to respond to the healthcare issues of diverse communities. Requires knowledge, capabilities and capacity at different levels of intervention: systemic, organisational, professional and individual. Providing healthcare that is culturally responsive = high quality and and safe healthcare.

8 2. Policy conceptualisation and implementation A new approach Absence of standards Developed with health services and the community Launched in September 2009 Congruent with legislative and policy frameworks and current research

9 2. Policy conceptualisation and implementation The framework promotes a whole-of-agency response and a systems approach to diverse health needs by: leading, governing and managing for cultural responsiveness communicating, collaborating and building community capacity across the health service linking health services planning and implementation within a quality and safety improvement framework building a more culturally responsive workforce and changes in professional practices at all levels.

10 2. Policy conceptualisation and implementation Determines a minimum level of activity in four domains of quality and safety 1.Organisational effectiveness 2.Risk management 3.Consumer participation 4.Effective workforce

11 3. Standards and performance measures Six Standards 1.A whole-of-organisation approach to cultural responsiveness is demonstrated 2.Leadership for cultural responsiveness is demonstrated by the health service 3. Accredited interpreters are provided to patients who require one

12 3. Standards and performance measures 4.Inclusive practice in care planning is demonstrated, including but not limited to dietary, spiritual, family, attitudinal, and other cultural practices 5.CALD consumer, carer and community members are involved in the planning, improvement and review of programs and services on an ongoing basis 6.Staff at all levels are provided with professional development opportunities to enhance their cultural responsiveness

13 3. Standards and performance measures Standard 3 Accredited interpreters are provided to patients who require one Measure 3.1 Numerator: Number of CALD consumers/patients identified as requiring an interpreter and who receive accredited interpreter services _____________________________________ Denominator: Number of CALD consumers/patients presenting at the health service identified as requiring interpreter services Standard 3 Accredited interpreters are provided to patients who require one

14 3. Standards and performance measures Lessons learned Health service participation – Testing the draft framework and standards with health services prior to implementation Consultation and discussion with health services across the state Drawing from an international research and evidence base Setting standards to work towards over time Linking standards to existing reporting requirements Data: some not currently collected or recorded A progression of building upon successful practices towards culturally responsive healthcare and integrated with key policy and legislative frameworks Aspiration can foster motivation.

15 4. Achievements and promising practices Alignment of cultural responsiveness with quality and safety in health care delivery Promoted a higher standard of planning for culturally responsive healthcare Health services have a 3-4 year Cultural Responsiveness Plan linked to strategic plan and other policy and reporting frameworks Significantly, many health services have exceeded the minimum requirements by additionally addressing all sub measures within the framework.

16 4. Achievements and promising practices Legitimisation and contextualisation of cultural responsiveness as a core health service activity Monitoring of standards and development of benchmarks over time Adaptation of framework by a variety of health care organisations Development of innovative research activities and service delivery models and resources at a health service level.

17 4. Achievements and promising practices Developing our own evidence – Northern Health

18 4. Achievements and promising practices Develop a health literacy and information policy statement Review Language Services policy Collect provision of interpreter data across various data sets Map initiatives against the National Safety and Quality Health Service Standards: Standard 2 – Partnering with consumers Measuring patient experience: Victorian Health Experience Measurement Instrument At health service level - review and improve service delivery for culturally and linguistically diverse consumers, including the provision of interpreters.

19 5. Emerging research initiatives Participation in global initiatives WHO-Health Promoting Hospitals Task Force on Migrant Friendly and Culturally Competent Health Care. Pilot-testing of Access and Equity Standards. Five key areas: equity in policy; equitable access and utilisation; equitable quality of care; inclusive user and community involvement; and promoting equity. Four Victorian public hospitals have participated in this pilot- testing.

20 5. Emerging research initiatives Cochrane Systematic Review Cultural competence education for health professionals To assess the effects of cultural competence education interventions for health professionals on patient-related outcomes. Why? Building a more culturally responsive workforce and changes in professional practices at all levels. Standard 6: Staff at all levels are provided with professional development opportunities to enhance their cultural responsiveness.

21 5. Emerging research initiatives The evidence gap Cultural competence education interventions are numerous and diverse in foci. Evidence that they can improve the knowledge, skills and attitudes of health professionals. A paucity of evidence to show their effectiveness in improving patient health outcomes.

22 5. Emerging research initiatives 1. Educational content 2. Pedagogical approach 3. Structure of the intervention 4. Participant characteristics a.Types of knowledge b. Assessment and application c. Skills Teaching and learning method Theoretical constructs and principles Evidence and research a. Delivery and format b. Frequency and timing c. Assessment and evaluation of intervention d. Organisational support Delivering the intervention (teacher/facilitator) Engaging in the intervention (target audience)

23 5. Emerging research initiatives Focusing on outcomes Educational interventions for health professionals working in health settings (hospital, community health, and aged care) aimed (either implicitly or explicitly) at improving: 1.Patient level: health outcomes of patients/consumers of culturally and linguistically diverse backgrounds 2.Health professional level: knowledge, skills and attitudes of health professionals in delivering culturally-competent care 3.Healthcare organisation level: healthcare organisation performance in culturally competent care.

24 5. Emerging research initiatives Studies Four cluster-RCTs and one RCT met the review's inclusion criteria. The studies were conducted in three countries: USA, Canada,The Netherlands One ongoing study with an estimated completion date of 2014, was also identified (Studies awaiting classification). The studies involved 337 health care providers and 8400 patients, of which at least 3,409 (40.5%) were from culturally and linguistically diverse (CALD) backgrounds.

25 5. Emerging research initiatives Multi-faceted programs Sessions held on more than one occasion [2.5 days; 36 hrs; monthly performance feedback reports] Directed at health professionals and some directed at patients as well Single-faceted programs Half-day sessions for health professionals with no patient intervention

26 5. Emerging research initiatives Primary outcome areas – patient level Treatment outcomes (3 studies) Client health outcomes (measured via Physical & Mental Health Assessment) Rate of achieving clinical control targets within preceding 12 months for LDL cholesterol (diabetes) Change in patient weight (diabetes) Involvement in care (2 studies) Mutual understanding between GP and patient Expenditure of Health Care & Social Services Evaluations of care (4 studies) Patient satisfaction with consultation Patient satisfaction Patient reported physician cultural competency Client perception of health professional (counsellors)

27 5. Emerging research initiatives Secondary outcome categories – health professional level Knowledge and understanding (2 studies) Improved understanding cultural attitudes Clinician awareness of racial differences in the quality of care among black clients Of note: No health behaviour outcome categories reported (primary outcome ) No outcomes reported at health organisation level.

28 5. Emerging research initiatives Preliminary observations Small number of included studies: few studies of this type (RCTs) conducted Studies are heterogeneous: study design, duration, outcomes, intervention, reporting of results Quality of studies (randomisation, unit of analysis issues, acceptability of evidence) Feasibility of research, cost, time span, individual vs. population changes Interest in field but still reveals a lack of consensus regarding what is important to measure.

29 5. Emerging research initiatives Education interventions – conceptual framework All domains addressed in some way across all studies. Absence of consensus: content, models and definitions The domain least present was the organsational support component of Domain 3. Structure of the intervention. Cultural competence education interventions for health professionals beneficial for health professionals. Emerging evidence for possible benefits for patients in involvement in care.

30 5. Emerging research initiatives What can we learn? Primary outcomes - at patient level: ascertain level of difference (statistically) Correlate all outcome areas across the conceptual framework for education intervention content Determine if and how the intervention can produce positive outcomes – for patients and health professional knowledge and skills Review findings to be used to develop an education framework for application in Victorian health services context Pilot testing of intervention in Victorian health services.

31 Thankyou Cultural responsiveness framework: Guidelines for Victorian health services www.health.vic.gov.au/cald/cultural-responsiveness-framework Cultural competence education for health professionals :Cochrane Library http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009405/abstract E-mail me at lidia.horvat@health.vic.gov.au (03) 9096 9008


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