cultural responsiveness: a prescription for a better health system lidia horvat policy &...

Cultural responsiveness:

a prescription for a better health system

Lidia Horvat

Policy & Strategy Unit, Quality, Safety & Patient Experience Branch

Department of Health, Victoria

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


• 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.


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).


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


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.


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.


• A new approach

• Absence of standards

• Developed with health services and the community

• Launched in September 2009

• Congruent with legislative and policy frameworksand current research


The framework promotes a whole-of-agency response and asystems 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 service’s planning and implementation within a quality and safety improvement framework

• building a more culturally responsive workforce and changes in professional practices at all levels.


Determines a minimum level of activity in four domains of qualityand safety

1. Organisational effectiveness

2. Risk management

3. Consumer participation

4. Effective workforce


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


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


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


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.


• 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.


• 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.


Developing our own evidence – Northern Health


• 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.


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.


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.


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.


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)


Focusing on outcomes

Educational interventions for health professionals working inhealth 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.


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.


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


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)


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.


Preliminary observations

• Small number of included studies: few studies of this type (RCT’s) 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.


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.


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.

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

[email protected]

(03) 9096 9008

http://www.health.vic.gov.au/cald/cultural-responsiveness-framework

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009405/abstract

mailto:[email protected]

cultural responsiveness: a prescription for a better health system lidia horvat policy &...

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