1. www.qualityforum.org A Nationally Endorsed Framework for Measuring and Reporting Culturally Competent Care Nicole W. McElveen, MPH Senior Project Manager, Performance Measures National Quality Forum

2. www.qualityforum.org Overview of NQF NQF Mission To improve the quality of American healthcare by Setting national priorities and goals for performance improvement, Endorsing national consensus standards for measuring and publicly reporting on performance, and Promoting the attainment of national goals through education and outreach programs. 2

3. www.qualityforum.org Discussion Points Summarize NQF’s work to date on disparities and cultural competency Review the components of the NQF-Endorsed ® framework for cultural competency Provide an overview of NQF’s current and future work on disparities and cultural competency 3

4. www.qualityforum.org (2001) Identified 10 specific recommendations to engage all stakeholders in reducing disparities through measurement and reporting. Completed Work 4 (2006) Endorsed 35 “disparity- sensitive” measures at the clinician-level of measurement (2009) Endorsed comprehensive framework and 45 preferred practices for measuring and reporting quality of culturally competent care

5. www.qualityforum.org Reducing Disparities Through Culturally Competent Care 5 Diverse Populations Cultural Competency Appropriate Services for Populations with Healthcare Disparities Improved Outcomes Equity and Patient- Centered Care Adapted from Brach C, Fraser I, Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model, Med Care Res Rev, 2000; 57 (suppl1): 181 – 217.

6. www.qualityforum.org Identifying a Framework for Cultural Competent Care Framework, logic model, or definition needed that would move the field beyond race or ethnic-specific interventions Framework around cultural competency serves as a road map for organizations delivering care and assists to identify gaps on practices Framework intended to be comprehensive and applicable to all healthcare settings and providers of healthcare Frameworks Preferred Practices Performance Measures 6

7. www.qualityforum.org NQF Cultural Competency Project In 2009, NQF endorsed a framework and preferred practices for measuring and reporting cultural competency NQF also identified high-priority research and measure development needs to advance evaluation of cultural competency Built consensus around major questions: √ What constitutes culturally competent care? √ Who is accountable to ensure it is delivered? √ How do health systems and providers measure cultural competency? √ Can we attribute culturally competent healthcare to improved health outcomes? 7

8. www.qualityforum.org Defining Cultural Competency Cultural competency is the ongoing capacity of healthcare systems, organizations, and professionals to provide for diverse patient populations high quality care that is safe, family- and patient- centered, evidence-based, and equitable. 8

9. www.qualityforum.org Cultural Competency Framework - Components Principles are overarching and/or cross-cutting across all (or multiple) domains of the framework Domains are the major areas of high-quality, culturally competent care Sub-domains further delineate the components of each domain 9

10. www.qualityforum.org Cultural Competency Framework - Principles Cultural competency in healthcare embraces the concept of equity and equal access to quality care. Cultural competency should be viewed as an ongoing process and a multilevel approach. Cultural competency is necessary, but not sufficient, to achieving an equitable healthcare system. The successful implementation of cultural competency initiatives requires an organizational commitment with a systems approach. 10 Four Guiding Principles

11. www.qualityforum.org Cultural Competency Framework - Domains 1.Leadership 2.Integration into management systems and operations 3.Patient-provider communication 4.Care delivery and supporting mechanisms 5.Workforce diversity and training 6.Community engagement 7.Data collection, public accountability, and quality improvement 11

12. www.qualityforum.org Development of Framework Referenced existing frameworks with principles for defining and identifying cultural competence from the IOM, Joint Commission, AHRQ and others Began with nine domains which included governance, care supporting mechanisms, organizational information systems Ranked domains for organization and implementation 12

13. www.qualityforum.org Cultural Competency –Domain 1 1.Leadership Healthcare providers, clinical and organizational leaders, the Board of Trustees, and the community share responsibility for, and play an essential role in, developing and implementing cultural competency activities, setting policy and strategy, and monitoring organizational performance. Organizational culture Commitment to serving a diverse population Leadership diversity Dedicated staff and resources Policies Training and development 13

14. www.qualityforum.org Cultural Competency – Domain 2 2.Integration into Management Systems and Operations Focusing on whether cultural competency is integrated throughout all management and operations activities of the organization is an essential component to supporting the delivery of culturally competent care. Strategic planning Service planning Performance evaluation Reward systems Marketing and public relations 14

15. www.qualityforum.org Cultural Competency – Domain 3 3.Patient-Provider Communication Clear communication at all levels and at all times among patients, clinicians, and support staff is essential for effective and culturally competent care. Language access Interpreter services Translation services Health literacy strategies Knowledge of culture and social context Cultural awareness Cross-cultural communication skills Family centeredness 15

16. www.qualityforum.org Cultural Competency – Domain 4 4.Care Delivery and Supporting Mechanisms From the first encounter to the last, care delivery structures and supporting mechanisms – the delivery of care, the physical environment where it is delivered, and links to supportive services and providers – should support the provision of culturally competent care. Clinical encounter Physical environment Assessment tools Coordination of care Linkages with alternative medicine providers Health information technology 16

17. www.qualityforum.org Cultural Competency – Domain 5 5.Workforce Diversity and Training Ensuring workforce diversity and training is a way to provide more effective services for culturally diverse populations through proactive recruitment, retention, and promotion strategies. Diversity at all levels of the organization is important. Training and development activities should include state of-the-art content in cultural competency and should reflect organizational commitment to cultural competency. Recruitment and retention Training commitment and content 17

18. www.qualityforum.org Cultural Competency- Domain 6 6.Community Engagement Active outreach and the exchange of information, as well as community inclusion and partnership in organizational decision-making, help ensure the provision of culturally competent care. Community outreach Community representation in organizational decisionmaking Community investments Community-based participatory research (CBPR) 18

19. www.qualityforum.org Cultural Competency – Domain 7 7.Data Collection, Public Accountability, and Quality Improvement (QI) Organizations use these methodologies to collect the data needed to access their cultural competency, to access whether they perform routine self-assessments in this regard, and to assess whether they integrate cultural competency into their public accountability and quality improvement activities. Collection of patient cultural competency-related information Collection of community cultural competency-related information Quality improvement Accountability Assessment of patient experiences with care Performance management systems Self-assessments of cultural competency Documentation of cultural competency practices Documentation of cross-cultural complaints and resolutions 19

20. www.qualityforum.org Crosswalk – NQF Framework with CLAS Standards 20 CLAS StandardNQF Framework Domain Standard 8 : develop and implement plan with goals, policies to promote cultural and linguistic services Leadership Standard 8Integration into management systems and operations Standard 4: offer and provide language services Standard 5: provide written and verbal information in patients preferred language Standard 6: assure competence of bilingual staff and interpreters Standard 7: patient-related materials and signage in common language of service area Patient-provider communication Standard 1: ensure patients receive effective care compatible with their cultural beliefs Care delivery and supporting mechanisms Standard 2: implement strategies to recruit diverse staff Standard 3: staff receive education & training Workforce diversity and training Standard 11: maintain current profile of community served Standard 12: develop partnerships with communities Community engagement Standard 13: conflict and grievance resolution are culturally sensitive Standard 14: make available information about progress & successful innovations Data collection, accountability, and quality improvement

21. www.qualityforum.org Implementation Strategies and Measures Convened Expert Panel to identify implementation strategies and concepts for a survey measure related to the NQF-endorsed cultural competency framework and practices. Framework domains important for implementation: – Patient – provider communication – Leadership – Workforce diversity – Community engagement – Quality improvement 21

22. www.qualityforum.org NQF Planned Efforts Identify disparity-sensitive measures across NQF portfolio Promote the development of tools to measure the implementation of cultural competency practices Identify performance measures for measuring and reporting cross- cutting areas in cultural competency and disparities Address disparities for each of the NPP goals 22

23. www.qualityforum.org Comments / Questions Nicole W. McElveen, MPH Sr. Project Manager, Performance Measures nmcelveen@qualityforum.org 23