Performance measures and their benchmarks for assessing organizational cultural competency in behavioral health care service delivery

The Patient and Carer Race Equality Framework: a model to reduce mental health inequity in England and Wales

The Patient and Carer Race Equality Framework (PCREF) is an Organisational Competence Framework (OCF), recommended by the Independent Review of the Mental Health Act as a means to improve mental health access, experience and outcomes for people from ethnic minority backgrounds, particularly Black people. This is a practical framework that should be co-produced with and tailored to the needs of service users, based on quality improvement and place-based approaches. We aim to use the PCREF to address the longstanding epistemic justices experienced by people with mental health problems, particularly those from minoritised ethnic groups. We will outline the work that led to the proposal, the research on racial inequalities in mental health in the UK, and how the PCREF will build on previous interventions to address these. By taking these into account, the PCREF should support a high minimum standard of mental health care for all.

Cultural Competence and Humility in Infectious Diseases Clinical Practice and Research

Infectious diseases as a specialty is tilted toward social justice, and practitioners are frequently on the front lines of the battle against health inequity in practices that are diverse and sometimes cross international borders. Whether caring for patients living with the human immunodeficiency virus, tuberculosis, or Ebola, infectious diseases practitioners often interact with those at the margins of societies (eg, racial/ethnic/sexual/gender minorities), who disproportionately bear the brunt of these conditions. Therefore, cultural barriers between providers and patients are often salient in the infectious diseases context. In this article, we discuss cultural competence broadly, to include not only the knowledge and the skills needed at both the organizational and the individual levels to provide culturally appropriate care, but also to include "cultural humility"-a lifelong process of learning, self-reflection, and self-critique. To enhance the quality and the impact of our practices, we must prioritize cultural competence and humility and be mindful of the role of culture in the patient-provider-system interactions, in our larger healthcare systems, and in our research agendas and workforce development.

Can a continuous quality improvement program create culturally safe emergency departments for Aboriginal people in Australia? A multiple baseline study

Background

Providing culturally safe health care can contribute to improved health among Aboriginal people. However, little is known about how to make hospitals culturally safe for Aboriginal people. This study assessed the impact of an emergency department (ED)-based continuous quality improvement program on: the accuracy of recording of Aboriginal status in ED information systems; incomplete ED visits among Aboriginal patients; and the cultural appropriateness of ED systems and environments.

Methods

Between 2012 and 2014, the Aboriginal Identification in Hospitals Quality Improvement Program (AIHQIP) was implemented in eight EDs in NSW, Australia. A multiple baseline design and analysis of linked administrative data were used to assess program impact on the proportion of Aboriginal patients correctly identified as Aboriginal in ED information systems and incomplete ED visits in Aboriginal patients. Key informant interviews and document review were used to explore organisational changes.

Results

In all EDs combined, the AIHQIP was not associated with a reduction in incomplete ED visits in Aboriginal people, nor did it influence the proportion of ED visits made by Aboriginal people that had an accurate recording of Aboriginal status. However, in two EDs it was associated with an increase in the trend of accurate recording of Aboriginality from baseline to the intervention period (odds ratio (OR) 1.31, p < 0.001 in ED 4 and OR 1.15, p = 0.020 in ED 5). In other words, the accuracy of recording of Aboriginality increased from 61.4 to 70% in ED 4 and from 72.6 to 73.9% in ED 5. If the program were not implemented, only a marginal increase would have occurred in ED 4 (from 61.4 to 64%) and, in ED 5, the accuracy of reporting would have decreased (from 72.6 to 71.1%). Organisational changes were achieved across EDs, including modifications to waiting areas and improved processes for identifying Aboriginal patients and managing incomplete visits.

Conclusions

The AIHQIP did not have an overall effect on the accuracy of recording of Aboriginal status or on levels of incomplete ED visits in Aboriginal patients. However, important organisational changes were achieved. Further research investigating the effectiveness of interventions to improve Aboriginal cultural safety is warranted.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4049-6) contains supplementary material, which is available to authorized users.

Organisational systems' approaches to improving cultural competence in healthcare: a systematic scoping review of the literature

INTRODUCTION

Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research.

METHODS

A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported.

RESULTS

Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level.

DISCUSSION AND IMPLICATIONS

We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities.

Prevalence and correlates of local health department activities to address mental health in the United States

Mental health has been recognized as a public health priority for nearly a century. Little is known, however, about what local health departments (LHDs) do to address the mental health needs of the populations they serve. Using data from the 2013 National Profile of Local Health Departments - a nationally representative survey of LHDs in the United States (N=505) - we characterized LHDs' engagement in eight mental health activities, factors associated with engagement, and estimated the proportion of the U.S. population residing in jurisdictions where these activities were performed. We used Handler's framework of the measurement of public health systems to select variables and examined associations between LHD characteristics and engagement in mental health activities using bivariate analyses and multilevel, multivariate logistic regression. Assessing gaps in access to mental healthcare services (39.3%) and implementing strategies to improve access to mental healthcare services (32.8%) were the most common mental health activities performed. LHDs that provided mental healthcare services were significantly more likely to perform population-based mental illness prevention activities (adjusted odds ratio: 7.1; 95% CI: 5.1, 10.0) and engage in policy/advocacy activities to address mental health (AOR: 3.9; 95% CI: 2.7, 5.6). Our study suggests that many LHDs are engaged in activities to address mental health, ranging from healthcare services to population-based interventions, and that LHDs that provide healthcare services are more likely than others to perform mental health activities. These findings have implications as LHDs reconsider their roles in the era of the Patient Protection and Affordable Care Act and LHD accreditation.

Cultural Issues in Psychiatric Administration and Leadership

This paper addresses cultural issues in psychiatric administration and leadership through two issues: (1) the changing culture of psychiatric practice based on new clinician performance metrics and (2) the culture of psychiatric administration and leadership in light of organizational cultural competence. Regarding the first issue, some observers have discussed the challenges of creating novel practice environments that balance business values of efficient performance with fiduciary values of treatment competence. This paper expands upon this discussion, demonstrating that some metrics from the Centers for Medicare & Medicaid Services, the nation's largest funder of postgraduate medical training, may penalize clinicians for patient medication behaviors that are unrelated to clinician performance. A focus on pharmacotherapy over psychotherapy in these metrics has unclear consequences for the future of psychiatric training. Regarding the second issue, studies of psychiatric administration and leadership reveal a disproportionate influence of older men in positions of power despite efforts to recruit women, minorities, and immigrants who increasingly constitute the psychiatric workforce. Organizational cultural competence initiatives can diversify institutional cultures so that psychiatric leaders better reflect the populations they serve. In both cases, psychiatric administrators and leaders play critical roles in ensuring that their organizations respond to social challenges.

CULTURALLY COMPETENT SERVICES WITHIN A STATEWIDE BEHAVIORAL HEALTHCARE TRANSFORMATION: A MIXED-METHOD ASSESSMENT

In 2005, New Mexico created a single health plan to administer all publicly-funded behavioral health services. Our mixed-method study combined surveys, document review, and ethnography to examine this reform's influence on culturally competent services (CCS). Participants were executives, providers, and support staff of behavioral healthcare agencies. Key variables included language access services and organizational supports, i.e., training, self-assessments of CCS, and maintenance of client-level data. Survey and document review suggested minimal effects on statewide capacity for CCS during the first three years of the reform. Ethnographic research helped explain these findings: (1) state government, the managed behavioral health plan and agencies failed to champion CCS; and (2) increased administrative requirements minimized time and financial resources for CCS. There was also insufficient appreciation among providers for CCS. Although agencies made progress in addressing language assistance services, availability and quality remained limited.

Racial and ethnic differences in substance abuse treatment initiation and engagement

This study examined variations by race and ethnicity in initiation and engagement, two performance measures of treatment for substance use disorders that focus on the timely receipt of services during the early stage of substance abuse treatment. Administrative data from the Oklahoma Department of Mental Health and Substance Abuse Services were linked with facility-level information from the National Survey of Substance Abuse Treatment Services. We found that Black clients were least likely to initiate treatment, but no race or ethnic differences in treatment engagement were found when compared by race or ethnicity. Most client and facility characteristics' association with initiation or engagement did not differ across racial or ethnic groups. Increased attention is needed to understand what may contribute to the differences and how to address them. This study also offers an approach that state agencies may implement for monitoring treatment quality and examining racial and ethnic disparities in substance abuse treatment services.

Methods in public health services and systems research: a systematic review

CONTEXT

Public Health Services and Systems Research (PHSSR) is concerned with evaluating the organization, financing, and delivery of public health services and their impact on public health. The strength of the current PHSSR evidence is somewhat dependent on the methods used to examine the field. Methods used in PHSSR articles, reports, and other documents were reviewed to assess their methodologic strengths and challenges in light of PHSSR goals.

EVIDENCE ACQUISITION

A total of 364 documents from the PHSSR library met the inclusion criteria as empirical and based in the U.S. After additional exclusions, 327 of these were analyzed.

EVIDENCE SYNTHESIS

A detailed codebook was used to classify articles in terms of (1) study design; (2) sampling; (3) instrumentation; (4) data collection; (5) data analysis; and (6) study validity. Inter-coder reliability was assessed for the codebook; once it was found reliable, the available empirical documents were coded.

CONCLUSIONS

Although there has been a dramatic increase in the amount of published PHSSR recently, methods used remain primarily cross-sectional and descriptive. Moreover, although appropriate for exploratory and foundational work in a new field, these approaches are limiting progress toward some PHSSR goals. Recommendations are given to advance and strengthen the methods used in PHSSR to better meet the goals and challenges facing the field.

Performance indicators for public mental healthcare: a systematic international inventory

Background

The development and use of performance indicators (PI) in the field of public mental health care (PMHC) has increased rapidly in the last decade. To gain insight in the current state of PI for PMHC in nations and regions around the world, we conducted a structured review of publications in scientific peer-reviewed journals supplemented by a systematic inventory of PI published in policy documents by (non-) governmental organizations.

Methods

Publications on PI for PMHC were identified through database- and internet searches. Final selection was based on review of the full content of the publications. Publications were ordered by nation or region and chronologically. Individual PI were classified by development method, assessment level, care domain, performance dimension, diagnostic focus, and data source. Finally, the evidence on feasibility, data reliability, and content-, criterion-, and construct validity of the PI was evaluated.

Results

A total of 106 publications were included in the sample. The majority of the publications (n = 65) were peer-reviewed journal articles and 66 publications specifically dealt with performance of PMHC in the United States. The objectives of performance measurement vary widely from internal quality improvement to increasing transparency and accountability. The characteristics of 1480 unique PI were assessed. The majority of PI is based on stakeholder opinion, assesses care processes, is not specific to any diagnostic group, and utilizes administrative data sources. The targeted quality dimensions varied widely across and within nations depending on local professional or political definitions and interests. For all PI some evidence for the content validity and feasibility has been established. Data reliability, criterion- and construct validity have rarely been assessed. Only 18 publications on criterion validity were included. These show significant associations in the expected direction on the majority of PI, but mixed results on a noteworthy number of others.

Conclusions

PI have been developed for a broad range of care levels, domains, and quality dimensions of PMHC. To ensure their usefulness for the measurement of PMHC performance and advancement of transparency, accountability and quality improvement in PMHC, future research should focus on assessment of the psychometric properties of PI.

A case study of organisational cultural competence in mental healthcare

Background

Ensuring Cultural Competence (CC) in health care is a mechanism to deliver culturally appropriate care and optimise recovery. In policies that promote cultural competence, the training of mental health practitioners is a key component of a culturally competent organisation. This study examines staff perceptions of CC and the integration of CC principles in a mental healthcare organisation. The purpose is to show interactions between organisational and individual processes that help or hinder recovery orientated services.

Methods

We carried out a case study of a large mental health provider using a cultural competence needs analysis. We used structured and semi-structured questionnaires to explore the perceptions of healthcare professionals located in one of the most ethnically and culturally diverse areas of England, its capital city London.

Results

There was some evidence that clinical staff were engaged in culturally competent activities. We found a growing awareness of cultural competence amongst staff in general, and many had attended training. However, strategic plans and procedures that promote cultural competence tended to not be well communicated to all frontline staff; whilst there was little understanding at corporate level of culturally competent clinical practices. The provider organisation had commenced a targeted recruitment campaign to recruit staff from under-represented ethnic groups and it developed collaborative working patterns with service users.

Conclusion

There is evidence to show tentative steps towards building cultural competence in the organisation. However, further work is needed to embed cultural competence principles and practices at all levels of the organisation, for example, by introducing monitoring systems that enable organisations to benchmark their performance as a culturally capable organisation.

The Nathan Kline Institute cultural competency assessment scale: psychometrics and implications for disparity reduction

The NKI Cultural Competency Assessment Scale measures organizational CC in mental health outpatient settings. We describe its development and results of tests of its psychometric properties. When tested in 27 public mental health settings, factor analysis discerned three factors explaining 65% of the variance; each factor related to a stage of implementation of CC. Construct validity and inter-rater reliability were satisfactory. In tests of predictive validity, higher scores on items related to linguistic and service accommodations predicted a reduction in service disparities for engagement and retention outcomes for Hispanics. Disparities for Blacks essentially persisted independent of CC scores.

Enhancing the cultural competency of health-care organizations

According to the Census, racial/ethnic minority populations are growing at such a fast rate that by 2050 more than 50% of the population will belong to a minority group (US Census, 2001). The increasing diversity of the U.S. population is one of the many changes that health-care delivery organizations need to proactively address in order to better serve their community and improve their performance. In this paper, we argue that cultural competency not only is important from a societal perspective, i.e., reducing health disparities, but can also be a strategy for health-care organizations to improve quality, lower cost, and attract customers. We provide detailed recommendations for health-care leaders and managers to adopt in order to successfully serve a diverse patient population.

Transforming administrative and clinical practice in a public behavioral health system: an ethnographic assessment of the context of change

In July 2005, New Mexico placed all publicly funded behavioral health services under the management of one private corporation. This reform emphasized the provision of evidence-based, culturally competent services. Methods. Participant observation and semi-structured interviews with 189 administrators, staff, and providers were carried out in 14 behavioral health safety-net institutions (SNIs) during the transition period. Results. New administrative requirements led to substantial paperwork demands, payment problems, and financial stress within SNIs. Personnel at the SNIs often lacked knowledge about and training in evidence-based practices and culturally competent care, and viewed the costs of delivering such services as prohibitive. Discussion. Policymakers must account for the challenges that SNIs face as the reform continues to unfold. The financial stability of SNIs is of critical importance. Efforts are needed to increase training and development opportunities in evidence-based care and cultural competency; SNIs typically lack resources to pursue these opportunities on their own.

Capacity for delivering culturally competent mental health services in New Mexico: results of a statewide agency survey

The Federal government has promoted National Standards for Culturally and Linguistically Appropriate Services (CLAS) to reduce mental health disparities among Hispanic and Native American populations. In 2005, the State of New Mexico embarked upon a comprehensive reform of its behavioral health system with an emphasis on improving cultural competency. Using survey methods, we examine which language access services (i.e., capacity for bilingual care, interpretation, and translated written materials) and organizational supports (i.e., training, self-assessments of cultural competency, and collection of cultural data) mental health agencies in New Mexico had at the onset of a public sector mental health reform (Office of Minority Health 2001).

Does the number of system paramedics affect clinical benchmark thresholds?

OBJECTIVE

Competency is affected by skill exposure, skill complexity, and training program quality. The purpose of this study was to reevaluate the biennial (24-month) critical care skill and experience benchmark thresholds established by the Milwaukee County Emergency Medical Services (MCEMS) system in 1997.

METHODS

This was a retrospective review of annual experience profiles for paramedics working during 2001-2005 using the MCEMS patient care record (PCR) database. The number of patient contacts, role as team leader/report writer, adult and pediatric endotracheal intubations, adult and pediatric intravenous (IV) access initiations, medication administration, and 12-lead electrocardiogram (ECG) acquisitions were analyzed. t-tests and descriptive statistics were performed for comparison with the 1997 study.

RESULTS

Over the five-year study period, 1,215 paramedic profiles gleaned from 107,524 PCRs documented a total of 297,900 patient contacts. Annual means+/-standard deviations [ranges] were as follows: patient contacts 245+/-133 [12-788]; team leader: 106+/-119 [0-739]; intubations: adult 2.57+/-2.54 [0-20], pediatric 0.1+/-0.3 [0-3]; IV starts: adult 44+/-37 [0-267], pediatric 0.34+/-0.77 [0-5]; treated cardiac arrests: adult 8+/-6 [0-34], pediatric 0.26+/-0.61 [0-4]; treated hypotensive trauma: 5+/-6 [0-42]; and ECGs acquired: 31+/-19 [0-144]. The 1997 analysis (1987-1996 data) included 1,450 paramedic profiles representing 467,559 patient contacts generated from 172,131 filed PCRs. All comparable experiences decreased significantly between the 1997 analysis and the current study, except medication administration, which increased 25%.

CONCLUSION

These data show a decreased opportunity and a wide variability in the frequency of successfully completed paramedic technical skills and experiences in this EMS system. Limited exposure to critically ill adult and pediatric patients reaffirms that high-risk skills are performed infrequently. A multifaceted approach should be considered for maintaining provider competency.

Implementation of culturally and linguistically competent policies by state Title V Children with Special Health Care Needs (CSHCN) programs

OBJECTIVE

This descriptive study was intended to identify actual actions, steps and processes of Children with Special Health Care Needs (CSHCN) programs to develop, implement, sustain and assess culturally and linguistically competent policies, structures and practices.

METHODS

An online 52-item mixed format survey of Maternal and Child Health (MCH) CSHCN directors was conducted. In April 2003 and May 2004, 59 directors were solicited to participate in the survey and 42 (86%) responded. Standard quantitative and qualitative analyses of the data were conducted to address key questions linked to the study's overall objective.

RESULTS

Findings indicated that almost all respondents are implementing some actions to provide culturally and linguistically competent services including adapting service practices, addressing workforce diversity, providing language access, engaging communities and including requirements in contracts. These individual actions were less often supported by processes such as self-assessment and creating an ongoing structure to systematically address cultural and linguistic competence. Programs are challenged to implement cultural and linguistic competence by state agency organization and budget restrictions.

CONCLUSIONS

The results of the study indicate a continued need for support within state MCH CSHCN programs in order to maintain or enhance the systematic incorporation of culturally and linguistically competent efforts.

Assessing implementation of cultural competency content in the curricula of colleges of pharmacy in the United States and Canada

OBJECTIVES

To assess the presence of curricular and organizational content related to cultural competency within colleges of pharmacy in the United States and Canada.

METHODS

Curriculum committee chairs (n = 87) and student leaders (n = 54) in colleges of pharmacy in the United States and Canada were surveyed via an e-mailed assessment tool.

RESULTS

Forty-nine (56.3%) curriculum committee chairs and 27 (50%) student leaders returned usable responses. Respondents reported that cultural competency was mentioned in 61.2% of their mission statements, and half had made curricular changes with respect to diversity within the past 5 years. Almost 94% felt the necessity to add cultural competency topics to required courses in the curriculum, and 42.9% wanted to add a course specific to cultural competency into the curriculum.

CONCLUSION

Curriculum committee chairs recognize the need to add curricular content related to cultural competency, but not all of the respondents have implemented changes in their college's curriculum.

Cultural competence in mental health care: a review of model evaluations

BACKGROUND

Cultural competency is now a core requirement for mental health professionals working with culturally diverse patient groups. Cultural competency training may improve the quality of mental health care for ethnic groups.

METHODS

A systematic review that included evaluated models of professional education or service delivery.

RESULTS

Of 109 potential papers, only 9 included an evaluation of the model to improve the cultural competency practice and service delivery. All 9 studies were located in North America. Cultural competency included modification of clinical practice and organizational performance. Few studies published their teaching and learning methods. Only three studies used quantitative outcomes. One of these showed a change in attitudes and skills of staff following training. The cultural consultation model showed evidence of significant satisfaction by clinicians using the service. No studies investigated service user experiences and outcomes.

CONCLUSION

There is limited evidence on the effectiveness of cultural competency training and service delivery. Further work is required to evaluate improvement in service users' experiences and outcomes.

Patients' perceptions of cultural factors affecting the quality of their medical encounters

OBJECTIVE

The aim of this study was to identify key domains of cultural competence from the perspective of ethnically and linguistically diverse patients.

DESIGN

The study involved one-time focus groups in community settings with 61 African-Americans, 45 Latinos and 55 non-Latino Whites. Participants' mean age was 48 years, 45% were women, and 47% had less than a high school education. Participants in 19 groups were asked the meaning of 'culture' and what cultural factors influenced the quality of their medical encounters. Each text unit (TU or identifiable continuous verbal utterance) of focus group transcripts was content analysed to identify key dimensions using inductive and deductive methods. The proportion of TUs was calculated for each dimension by ethnic group.

RESULTS

Definitions of culture common to all three ethnic groups included value systems (25% of TUs), customs (17%), self-identified ethnicity (15%), nationality (11%) and stereotypes (4%). Factors influencing the quality of medical encounters common to all ethnic groups included sensitivity to complementary/alternative medicine (17%), health insurance-based discrimination (12%), social class-based discrimination (9%), ethnic concordance of physician and patient (8%), and age-based discrimination (4%). Physicians' acceptance of the role of spirtuality (2%) and of family (2%), and ethnicity-based discrimination (11%) were cultural factors specific to non-Whites. Language issues (21%) and immigration status (5%) were Latino-specific factors.

CONCLUSIONS

Providing quality health care to ethnically diverse patients requires cultural flexibility to elicit and respond to cultural factors in medical encounters. Interventions to reduce disparities in health and health care in the USA need to address cultural factors that affect the quality of medical encounters.