Presentation on theme: "Cultural responsiveness: a prescription for a better health system"— Presentation transcript:
1 Cultural responsiveness: a prescription for a better health system Lidia HorvatPolicy & Strategy Unit, Quality, Safety & Patient Experience BranchDepartment of Health, Victoria
2 Outline Linking access, equity, quality and safety Policy conceptualisation and implementationStandards and performance measuresAchievements and promising practicesEmerging research initiatives
3 1. Linking access, equity, quality and safety Concretise the links between access & equity and quality & safetyAlign risk management, patient safety, quality improvement and cultural responsivenessEmbed cultural responsiveness into core health service planning and implementationA whole-of-organisation approachDevelop 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 careLinks 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 ContextUS hospitals pilot study: Divi et. al 2007Six Joint Commission accredited hospitalsAdverse event data collected over7 months in 2005 using National Quality Forum endorsed Patient Safety Event Taxonomy* LEP = Low English proficiencyResults49.1% of LEP patient adverse events involved some physical harm,compared with29.5% of English speaking patients adverse eventsOf those adverse events resulting in physical harm:46.8% of LEP patients had harm ranging from moderate temporary harm to death24.45 % of English speaking patientsOverall Communication errors:52.4% LEP patients35.9% English speaking patients
6 1. Linking access, equity, quality and safety Research and evidence base - benefitsReducing health care disparities and increasing access to healthcare: Jacobs et. al. 2004, Le Sage 2006Enhancing quality of care: Flores 2005, Karliner 2007Reduction of errors (clinical or interpreter): Cohen et. al.2005,Flores 2006, Gany et. al. 2007Improving patient health outcomes: Cohen et. al. 2005, Divi et. al. 2007, Flores 2005Reducing cost of services: Bernstein et. Al. 2002, Graham et. al. 2008, Jacobs et. AlEnhancing patient-provider communication: Bischoff et. al. 2008, Hablamos Juntos 2007b, Schenker et. Al. 2007, Ramirez et, al. 2008Risk 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 approachAbsence of standardsDeveloped withhealth servicesand the communityLaunched in September 2009Congruent with legislative andpolicy frameworksand current research
9 2. Policy conceptualisation and implementation The framework promotes a whole-of-agency response and asystems approach to diverse health needs by:leading, governing and managing for cultural responsivenesscommunicating, collaborating and building community capacity across the health servicelinking health service’s planning and implementation within a quality and safety improvement frameworkbuilding 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 qualityand safetyOrganisational effectivenessRisk managementConsumer participationEffective workforce
11 3. Standards and performance measures Six StandardsA whole-of-organisation approach to cultural responsiveness is demonstratedLeadership for cultural responsiveness is demonstrated by the health service3. 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 practices5. CALD consumer, carer and community members are involved in the planning, improvement and review of programs and services on an ongoing basis6. Staff at all levels are provided with professional development opportunities to enhance their cultural responsiveness
13 3. Standards and performance measures Accredited interpreters areprovided to patientswho require oneStandard 3Accredited interpreters areprovided to patientswho require oneMeasure 3.1Numerator: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
14 3. Standards and performance measures Lessons learnedHealth service participation – Testing the draft framework and standards with health services prior to implementationConsultation and discussion with health services across the stateDrawing from an international research and evidence baseSetting standards to work towards over timeLinking standards to existing reporting requirementsData: some not currently collected or recordedA progression of building upon successful practices towards culturally responsive healthcare and integrated with key policy and legislative frameworksAspiration can foster motivation.
15 4. Achievements and promising practices Alignment of cultural responsiveness with quality and safety in health care deliveryPromoted a higher standard of planning for culturally responsive healthcareHealth services have a 3-4 year Cultural Responsiveness Plan linked to strategic plan and other policy and reporting frameworksSignificantly, 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 activityMonitoring of standards and development of benchmarks over timeAdaptation of framework by a variety of health care organisationsDevelopment 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 statementReview Language Services policyCollect provision of interpreter data across various data setsMap initiatives against the National Safety and Quality Health Service Standards: Standard 2 – Partnering with consumersMeasuring patient experience: Victorian Health Experience Measurement InstrumentAt 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 initiativesWHO-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 ReviewCultural competence education for health professionalsTo assess the effects of cultural competence education interventionsfor health professionals on patient-related outcomes.Why?Building a more culturally responsive workforce and changes inprofessional practices at all levels.Standard 6: Staff at all levels are provided with professional developmentopportunities to enhance their cultural responsiveness.
21 5. Emerging research initiatives The evidence gapCultural 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 content2. Pedagogical approach3. Structure of the intervention4. Participant characteristicsTypes of knowledgeb. Assessment and applicationc. SkillsTeaching and learning methodTheoretical constructs and principlesEvidence and researcha. Delivery and formatb. Frequency and timingc. Assessment and evaluation of interventiond. Organisational support• Delivering the intervention (teacher/facilitator)• Engaging in the intervention (target audience)
23 5. Emerging research initiatives Focusing on outcomesEducational interventions for health professionals working inhealth settings (hospital, community health, and aged care) aimed(either implicitly or explicitly) at improving:Patient level: health outcomes of patients/consumers of culturally and linguistically diverse backgroundsHealth professional level: knowledge, skills and attitudes of health professionals in delivering culturally-competent careHealthcare organisation level: healthcare organisation performance in culturally competent care.
24 5. Emerging research initiatives StudiesFour cluster-RCTs and one RCT met the review's inclusion criteria.The studies were conducted in three countries: USA, Canada ,The NetherlandsOne ongoing study with an estimated completion date of 2014, was also identified (Studies awaiting classification).The studies involved 337 health care providers and patients, of which at least 3,409 (40.5%) were from culturally and linguistically diverse (CALD) backgrounds.
25 5. Emerging research initiatives Multi-faceted programsSessions 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 wellSingle-faceted programsHalf-day sessions for health professionals with no patient intervention
26 5. Emerging research initiatives Primary outcome areas – patient levelTreatment 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 patientExpenditure of Health Care & Social ServicesEvaluations of care (4 studies)Patient satisfaction with consultationPatient satisfactionPatient reported physician cultural competencyClient perception of health professional (counsellors)
27 5. Emerging research initiatives Secondary outcome categories – health professional levelKnowledge and understanding (2 studies)Improved understanding cultural attitudesClinician awareness of racial differences in the quality of care among black clientsOf note:No health behaviour outcome categories reported (primary outcome )No outcomes reported at health organisation level.
28 5. Emerging research initiatives Preliminary observationsSmall number of included studies: few studies of this type (RCT’s) conductedStudies are heterogeneous: study design, duration, outcomes, intervention, reporting of resultsQuality of studies (randomisation, unit of analysis issues, acceptability of evidence)Feasibility of research, cost, time span, individual vs. population changesInterest in field but still reveals a lack of consensus regarding what is important to measure.
29 5. Emerging research initiatives Education interventions – conceptual frameworkAll domains addressed in some way across all studies.Absence of consensus: content, models and definitionsThe 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 contentDetermine if and how the intervention can produce positive outcomes – for patients and health professional knowledge and skillsReview findings to be used to develop an education framework for application in Victorian health services contextPilot testing of intervention in Victorian health services.
31 ThankyouCultural responsiveness framework: Guidelines for Victorian health servicesCultural competence education for health professionals :Cochrane Libraryme at(03)