UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl)

UvA-DARE (Digital Academic Repository)

Cultural competence and diversity responsiveness: how to make a difference in healthcare?

Seeleman, M.C.

Link to publication

Citation for published version (APA):Seeleman, M. C. (2014). Cultural competence and diversity responsiveness: how to make a difference inhealthcare?.

General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s),other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).

Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, statingyour reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Askthe Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam,The Netherlands. You will be contacted as soon as possible.

Download date: 11 Jan 2021

This chapter has been submitted as:

Conny Seeleman, Marie-Louise Essink-Bot, Karien Stronks, David Ingleby. How should

health service organizations respond to diversity? An analytic framework based on a

comparison of six approaches.

Chapter 7 109

7 How should health service organizations

respond to diversity? An analytic

framework based on a comparison of six

approaches

110 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

Abstract

Context

Health care organizations need to be responsive to the needs of increasingly diverse

patient populations. We developed an analytic framework based on a comparison of six

approaches for organizational responsiveness to diversity. The central questions

addressed in this paper are: what are the essential elements of health services that are

responsive to the needs of groups differing from the majority population? How much

consensus is there between various approaches?

Methods

We selected six approaches from the US, Australia and Europe and used qualitative

analysis to categorize the content of each approach into ‘domains’ (conceptually distinct

topic areas) and, within each domain, into ‘dimensions’ (operationalizations). The

resulting classification framework was used for comparative analysis of the content of

the six approaches.

Findings

We identified seven domains that were represented in most or all approaches:

‘organizational commitment’, ‘empirical evidence on inequalities and needs’, ‘a

competent and diverse workforce’, ‘ensuring access for all users’, ‘ensuring

responsiveness in care provision’, ‘fostering patient and community participation’ and

‘actively promoting responsiveness’. Variations in the conceptualization of ‘responsive

care’ reflected different assumptions about the type of diversity that should be

responded to. For example, approaches that focus on ethnic diversity refer mostly to

cultural and language differences; approaches that broaden their target populations to

(e.g.) ‘vulnerable’ groups adopt a more multidimensional approach, also paying attention

to such factors as socio-economic status and gender.

Conclusions

According to current conceptualizations, organizational responsiveness to diversity

in health care means ensuring access and providing appropriate care. The analytic

framework also defines several preconditions, such as demonstrating organizational

commitment, developing a competent and diverse workforce, and fostering patient and

community participation. Despite differences in the way different approaches are

labeled, this comparative study reveals a broad consensus among different approaches

concerning the way in which health service organizations should respond to diversity.

Chapter 7 111

Introduction

Health service users belonging to groups that differ in certain respects from the

majority population, such as migrants, ethnic minorities and other groups sometimes

referred to as ‘vulnerable’, often receive poorer care than majority users. Variously

described as ‘health care disparities’, ‘inequalities’ or ‘inequities’, these problems in

healthcare have been well documented in the United States (1,2) and are increasingly

being recognized in other countries (3-5).

The existence of these problems implies that health services may need to be

adapted in order to increase their accessibility and quality for service users who differ

from assumed norms. Such responsiveness to diversity has for several decades been

referred to as ‘culturally competent care’. This concept was first developed in the USA in

relation to ethnic minorities, but in recent years there has been a growing realization

that many other groups are also not optimally served by standard services. In the USA,

the response has been to retain the label of ‘cultural competence’ but to broaden the

definition of ‘culture’ to reflect such attributes as migrant status, socioeconomic

position, geographical location, gender, religion, age, sexual orientation or disability

(6,7). In other countries, however, widening the range of target groups has been seen as

a shift away from the focus on ‘culture’. Rather than speaking of ‘cultural competence’,

advocates of responsiveness to diversity have used terms such as ‘promoting equitable

health care’, or ‘protecting vulnerable groups’ (8). Despite the differences in

terminology, we will argue in this paper that these disagreements are to a large extent a

question of semantics.

Whichever approach is adopted, promoting responsiveness to diversity requires

interventions at several levels of the health system. At the level of individual caregivers,

three elements of responsive care have been emphasized: knowledge, skills and

attitudes (9,10). At the level of health service organizations, promoting responsiveness

involves putting into place certain key elements in service policies and management (8).

Some approaches address the level of entire health systems, in which case interventions

at national (or state) as well as organizational or individual levels are discussed.

In this article we will examine only recommendations that have been put forward at

the organizational level, while recognizing that responsiveness to diversity also has

important implications for the other two levels. Approaches differ according to the

target group for which they were principally intended and the assumptions that underlie

them. In the USA, ‘cultural competence’ has been promoted at the organizational level

through the CLAS standards (Standards for Culturally and Linguistically Appropriate

Services) (11). In Europe, recommendations have been published referring to goals such

112 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

as ‘migrant friendliness’ (12), ‘intercultural opening’ (13), ‘transcultural competence’ (14)

or ‘difference sensitivity’ (15).

So far no systematic analyses have been carried out to establish whether there are

important differences in content between these approaches. To what extent does

consensus exist about the measures that organizations should take in order to adapt

health services to the needs of diverse patient populations? Without such consensus, no

general principles can be laid down for improving responsiveness, nor can general

criteria for measuring progress towards this goal be defined.

In this paper we have developed an over-arching analytic framework within which

different approaches can be described, compared and contrasted. The paper examines

six approaches and addresses the following questions:

1. On which aspects of health service provision (‘domains’) do the different

approaches focus?

2. How much agreement is there concerning the domains that are important?

3. How much agreement is there in the way the tasks within each domain are

operationalized in ‘dimensions’?

The answers to these questions will shed light on our central question: what are the

essential elements in providing care that is responsive to the needs of groups differing in

certain important respects from the majority population, and how much consensus is

there between various approaches?

Method

Choice of approaches

In recent years many guidelines or recommendations for increasing organizational

responsiveness to diversity have been published by both public and private bodies. To

compare all these approaches would have been an impossibly large task, so we selected

six approaches using the following criteria:

- the approach was developed for widespread (more than local) use;

- it was developed by an organization with some authority; and

- it was publicly available.

In addition, we wanted to compare approaches from US, Australian and European

sources.

The following approaches were selected: 1) CLAS Standards - National Standards for

Culturally and Linguistically Appropriate Services in Health Care (further referred to as:

CLAS) developed by the Office of Minority Health, part of the U.S. Department of Health

and Human Services (11); 2) Advancing Effective Communication, Cultural Competence,

Chapter 7 113

and Patient- and Family Centered Care: A Roadmap for Hospitals (further referred to as

JCR), developed by the Joint Commission (16); 3) Cultural Responsiveness Framework.

Guidelines for Victorian health services (further referred to as CRF) developed by the

Victorian Government, Department of Health (17); 4) Recommendation of the

committee of ministers to member states on mobility, migration and access to health

care (further referred to as COER) of the Council of Europe (18,19); 5) The Equality

Delivery System (further referred to as EDS) for the NHS (20); 6) Standards for Equity in

Health Care for Migrants and other Vulnerable Groups (further referred to as EQS)

developed by the Task Force on Migrant-Friendly and Culturally Competent (21). Box 7.1

briefly describes each approach and clarifies our reasons for including the approach in

our study.

In May 2013 the Enhanced CLAS Standards were published, entitled “National

Standards for Culturally and Linguistically Appropriate Services in Health and Health

Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice” (7). A

comparison of the new Standards with the original version showed that the underlying

ideas were virtually identical to those which informed the first edition. Indeed, the

accompanying texts made clear that the aim of the revision was mainly to increase the

effectiveness of the Standards, by explaining them more clearly, ensuring that they

reflected recent developments, and aligning them with other initiatives such as the

Affordable Care Act and the work of the Joint Commission. Some differences of emphasis

are described in Box 7.1. The version of CLAS used in this paper is the original one: we do

not feel the changes made in the enhanced version are extensive enough to warrant a

separate analysis.

Box 7.1 Description of the six approaches on responsive health care that were included.

CLAS Standards - National Standards for Culturally and Linguistically Appropriate

Services in Health Care (CLAS) (11). These standards were developed by the Office of

Minority Health, part of the U.S. Department of Health and Human Services. Some of the

standards have the status of mandates, meaning that they are Federal requirements for all

health care organizations that receive Federal funds; others are purely recommendations.

We included the CLAS standards because they are probably the most comprehensive and

influential approach in use. In May 2013 the Enhanced CLAS Standards were published (7).

Although largely similar, there are some differences of emphasis between the original and

the Enhanced CLAS Standard appeared of which we would like to mention:

A broader definition of “culture” was adopted. In the original version, culture was

defined as being “associated with racial, ethnic or linguistic groups”. In the new definition,

this was expanded to include “religious, spiritual, biological, geographical, or sociological

characteristics”, thus extending the relevance of CLAS standards beyond racial and ethnic

minorities to a wide range of types of diversity. Although many new groups are now

114 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

intended to fall under the scope of CLAS, the only feature of these groups which is taken

account of is still their culture (defined as an “integrated pattern of thoughts,

communications, actions, customs, beliefs, values, and institutions”). Other features such

as social position, material limitations or legal situation are not mentioned.

In the vision on responsive care some slight changes of emphasis could be found, such

as a shift from regarding diversity as a ‘group’ characteristic to ‘appreciating the diversity

of individuals’. The enhanced CLAS also places more emphasis on the importance of

‘patient- and family centred care’, thus bringing it more into line with the JC Roadmap

Advancing Effective Communication, Cultural Competence, and Patient- and Family

Centered Care: A Roadmap for Hospitals (JCR) (16). This ‘Roadmap’ has been developed

by the Joint Commission (JC), an independent, not-for-profit organization which accredits

and certifies health care organizations in the United States. The Roadmap was developed

in addition to existing JC requirements “to inspire hospitals to integrate concepts from the

fields of communication, cultural competence, and patient- and family-centered care into

their organizations.” We included the JC Roadmap because of the global influence of JC

and the Joint Commission International (JCI) accreditation program on health care

organizations through their accreditation programs (applied in over 50 countries).

Although attention to healthcare for ethnic minority patients within the JC started after a

‘gap’ analysis between the CLAS standards and the JC’s accreditation standards in 2003,

the JC has developed its own framework of recommendations on issues of effective

communication, cultural competence, and patient- and family-centered care. Therefore we

consider the Roadmap to be related to the CLAS standards, but distinct from them. It is

important to note that 1) existing JC requirements also include issues related to those

issues discussed in the Roadmap, and 2) that the national Joint Commission Standards are

different from the Standards of the Joint Commission International.

Cultural Responsiveness Framework. Guidelines for Victorian health services (CRF)

by the Rural and Regional Health and Aged Care Services, Victorian Government,

Department of Health (Australia) (17). The CRF was developed to replace the Health

Service Cultural Diversity Plans (HSCDPs) which since 2006 have required all Victorian

health services to develop and implement policies for ethnic diversity in care. The intention

of the CRF is to consolidate multiple requirements for reporting on cultural diversity

initiatives within health services. All Victorian health services are required to submit plans

and achievements according to the standards and measures in the CRF to the Statewide

Quality Branch. We included the CRF because it has been disseminated and made

compulsory in a large health care system in Australia.

Recommendation of the committee of ministers to member states on mobility,

migration and access to health care (COER) of the Council of Europe (18,19). The Council

of Europe is an international organization set up “to achieve a greater unity between its

members for the purpose of safeguarding and realizing the ideals and principles which are

their common heritage and facilitating their economic and social progress” (32). We

included the COER because it has been endorsed by the Health Ministers of the 47

Chapter 7 115

member states of the Council of Europe. The document is aimed at ministerial level,

therefore it includes recommendations that have consequences for the whole health

system. To make comparisons possible we have only included the recommendations at

organizational level in our analysis.

Equality Delivery System (EDS) for the NHS (20). EDS originates from the Equality and

Diversity Council within the British National Health Service (NHS). It is designed to help NHS

organizations to comply with the ‘Public Sector Equality Duty’ (PSED) of the Equality Act.

This act “requires public bodies to consider all individuals when carrying out their day to

day work – in shaping policy, in delivering services and in relation to their own employees”

(33). EDS is made available to the NHS as an optional tool. It was included because it is a

European instrument which has been disseminated in a large health care system.

Equity Standards (EQS) of the Task Force on Migrant-Friendly and Culturally

Competent Healthcare (21,25). These Standards were developed by a group of mainly

European experts set up within WHO’s Health Promoting Hospitals network. The Equity

Standards are a self-assessment instrument to enable health care organizations to carry

out an ‘equity evaluation’ against a set of standards. The instrument was piloted in 10

European countries, as well as in two non-European ones. The Equity Standards were

included because of the broad international context in which they were developed.

Developing the Framework

The following stepwise approach was used to develop the analytic framework.

A. Encoding of content

1. The first approach analyzed was CLAS. The different CLAS standards were

grouped into ‘domains ‘, i.e. conceptually distinct topic areas. Within each

domain, different ‘dimensions’ were distinguished in order to show how

the domain was operationalized.

2. A second approach was selected and its content was subsumed under the

domains and dimensions identified in Step 1, new ones being created

where necessary.

3. The four remaining approaches were treated in the same way.

4. The resulting system of domains and dimensions was critically reviewed by

three of the authors in order to remove ambiguities and overlap.

B. Comparison of content

Categorizing the content of the approaches in this over-arching classification system

enabled us to see at a glance whether certain domains were unique to, or absent from,

particular approaches. Within each domain, it revealed the differences in the ways in

which approaches operationalized the domain. In order to compare the six approaches,

we listed the differences between them as well as their similarities.

116 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

Results

This section starts with background information on the six approaches. We then

provide an overview and analysis of their content, classified according to the domains

and dimensions of the framework that we developed. We then describe the similarities

and differences between the six approaches.

Background information

Table 7.1 provides background information on the six approaches, listed with their

acronyms (Table 7.1: see end of this chapter).

As their aim, the approaches refer to reducing or eliminating existing inequalities in

health and quality of care between different populations (CLAS, COER, EQS), as well as

improving outcomes for patients (JCR, CRF, EDS). Although all approaches aim at

improving the quality of care, the motives underlying this goal are different. Some

approaches (CLAS, COER, EQS) start from human rights principles, regarding inequalities

between groups as injustices which should be eliminated. JCR considers equality as an

indicator of performance, assuming that outcomes should be equal for all patients, while

CRF and EDS combine both starting points. Two unique aims (not mentioned in other

approaches) also emerge: CRF aims to enhance the cost-effectiveness of health service

delivery, and EDS aims to create better working environments for staff.

In their vision on responsive care, three approaches directly invoke the concept of

‘cultural competence’. CLAS refers to the classic definition of cultural competence (Cross

et al. 1989 (34)); at the same time, the term ‘culturally and linguistically appropriate

services’ places separate and explicit emphasis on language issues. For JCR, cultural

competence is one of three fundamental concepts on which the Roadmap elaborates

(the other concepts being ‘effective communication’ and ‘patient and family centered

care’). JCR operationalizes cultural competence in a similar way to CLAS. CRF introduces

another concept: ‘culturally responsive care’. Although this term is chosen in preference

to ‘cultural competence’, the vision implied is very similar to that of CLAS and JCR. A

common characteristic of the first three approaches is therefore their emphasis on

‘culture’, at least in the labeling of their vision.

In the other three approaches the emphasis is not on ‘culture’ (as the presumed

cause of problems) but on ‘equity’ or ‘equality’ (as the hoped-for result of efforts to

tackle them). COER refers to “equitable access to health care of appropriate quality”: in

relation to service delivery, it speaks of “improving the adaptation of health service

provision to the needs, culture and social situation of migrants”. EDS does not provide a

definition of its concept of equality, but relates it to the pursuit of quality, which in turn

is defined as recognizing the needs and circumstances of all (both patients and staff) and

Chapter 7 117

ensuring accessibility, appropriateness, safety and effectiveness for patients. EQS

explicitly distances itself from the concept of ‘cultural competence’, instead highlighting

Whitehead’s definition of equity in health: “equal access to available care for equal need;

equal utilization for equal need; equal quality of care for all” (22).

The target population of each approach refers to the user groups envisaged by the

authors as beneficiaries. CLAS, JCR and CRF refer to the target population in terms of

race, ethnicity, culture or language, while EDS and EQS also include gender, age,

disability, religion, sexual orientation, transgender status (both EDS and EQS); marriage

and civil-partnership, pregnancy and maternity, nationality (only EDS); socio-economic

status and aboriginal status (EQS). COER focuses explicitly on migrants, a category that is

not mentioned explicitly in CLAS, JCR, CRF or EDS. However, COER uses the term migrant

“in a very broad sense, referring not only to those who change their country of residence

voluntarily but also to asylum seekers, refugees and victims of human trafficking. Since

the consequences of migration may also extend beyond the first generation, second and

later generations are also discussed. In the case of Internally Displaced Persons, internal

migrants are also included”. There is thus considerable overlap between the category of

‘migrants’ as defined by COER and the term ‘ethnic minorities’ used in other approaches.

‘Horizontal’ analysis (according to domains) (see table 7.2 at the end of this chapter)

1. Organizational commitment

Elements of the various approaches were classified in this domain if they mentioned

commitment at management level to responsiveness to diversity. Two dimensions were

found: policy and leadership and measurement of performance.

Policy and leadership

All six approaches maintain that organizations must make an explicit commitment to

developing responsive care, rather than merely permitting individual initiatives that are

not structurally imbedded in the organization. In COER this requirement is implied by

insistence on a ‘whole organization approach’. Commitment can either take the form of

an explicit plan (CLAS, EQS), which sets out how the organization intends to organize and

guarantee responsiveness, or a policy of good leadership (JCR, EDS), or both (CRF).

‘Good leadership’ is explicitly committed to achieving responsive care and promotes

this within the organization (JCR, EDS): leaders take responsibility for reaching this goal

(CRF). All approaches emphasize that plans for change should be integrated in existing

organizational policies and processes. EQS additionally promotes a ‘proactive’ approach:

in all its plans, the organization should anticipate the effect the plans will have on

accessibility and quality of care for vulnerable groups.

118 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

Measuring and improving performance

All approaches regard it as essential that organizations measure their performance

in providing responsive services (e.g. outcomes of treatment for different groups), with

the aim of identifying necessary improvements, taking action, and assessing the

organization’s progress in providing responsive care. CLAS, EDS and EQS further

emphasize that performance measurement should be a continuous activity, incorporated

in regular performance measurement systems. The approaches differ in the variables

which they suggest should be measured: some focus on quality of care, some on

accessibility, and some on both (see also the domain ‘collecting data’ for the data-

sources to be used in measuring and improving performance). CRF is the only approach

stipulating mandatory indicators for measuring organizational cultural responsiveness.

These have to be submitted by affiliated organizations and are also used for

benchmarking.

2. Collecting data

The second domain we identified concerns the collection of data, not as an end in

itself but because these data are necessary to measure equity of access and quality of

care and to identify special needs or opportunities for improvement (see also the domain

‘measuring and improving performance’). Two types of data are distinguished: one

concerns the population at large; the other concerns the organization’s own users.

Data on the population at large

Five approaches (CLAS, JCR, CRF, EDS, EQS) recommend assembling data on the

community or catchment area in order to adapt services to the needs thus identified.

Organizations can use information that is already available, but CLAS and EDS also give

organizations an active role in collecting these data themselves. Such data include

demographic variables (e.g. age, gender, ethnicity), characteristics potentially affecting

service use (e.g. language proficiency, health literacy), health status and exposure to

health risks. In COER the importance of empirical evidence is strongly emphasized:

governments are urged to collect it “in partnership with relevant organizations”.

Data on the patient population

Patients’ files can serve as a source of data on ethnicity, race, language and other

characteristics considered relevant for quality of care. For CLAS, JCR, CRF, and EQS these

data are considered important in order to identify and monitor health and health care

inequalities. For CLAS, JCR and EQS, information in patients’ files on individual

characteristics associated with ethnic minority status (e.g. proficiency in the majority

language) also enables adaptation of care to the needs of an individual patient.

Additionally CLAS, JCR, CRF, EDS and EQS emphasize that outcome measures and patient

Chapter 7 119

feedback systems must be able to analyze results according to diversity characteristics.

The approaches differ in the types of data they recommend organizations to collect.

3. Staff/Workforce

The third domain concerns the staff or workforce of the organization. Two

dimensions can be distinguished: staff competencies and diversity in the workforce.

Staff competencies

Staff competencies in delivering responsive care, and the importance of education

and training, are central themes in all approaches. CRF and EDS describe a

comprehensive approach to improving confidence and competence among staff, for

example through personal development programs (EDS) and adapted HRM policies

(CRF). CLAS, CRF, COER and EQS emphasize that all staff should be trained (CLAS even

includes affiliated and subcontracted staff); CLAS, CRF and EQS also recommend

monitoring the effects of training. CLAS recommends separate training in the provision

of responsive care, JCR recommends the incorporation of such training in the existing

curriculum, while COER and EQS support both. The approaches vary in the amount of

information they provide on the content of training.

Diversity in the workforce

According to CLAS, JCR and COER, diversity among staff members is desirable for

furthering responsiveness to patient diversity. Two arguments are given for the

importance of staff diversity. The first is general: the workforce should be representative

of the general population (CLAS, COER). The second is more specific: staff diversity is

considered to further equity by making possible a higher degree of linguistic and ethnic

concordance between patients and staff (CLAS, JCR). EDS and EQS discuss this issue from

the perspective of equality among staff and include objectives for inclusive Human

Resource policies relating to issues such as recruitment. CRF does not address the issue

of staff diversity.

4. Ensuring access

All issues relating to barriers to entering the healthcare organization were classified

under this heading. The dimensions that emerged concerned entitlement to care, the

provision of understandable information, and issues concerning geographical and other

aspects of accessibility. Some issues discussed in this domain reappear in the domain of

‘care provision’, because they are also relevant to the caregiving relationship.

Entitlement to care

Entitlement to care (i.e. whether patients are insured or are allowed to use national

health services) is not mentioned in CLAS, JCR, CRF and EDS. This is understandable to

120 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

the extent that entitlement is an issue covered by legislation and insurance rules, rather

than by the policies of service providers. If service providers choose to give care outside

the framework of formal entitlements, this is left to their own discretion. However, EQS

goes a step further and charges organizations with a responsibility for patients who are

not eligible for care: it urges that at the very least, steps should be taken to help them

find appropriate care elsewhere. COER, which includes recommendations at health

system level, makes a plea for “adequate entitlements to use of health services”:

concerning the role of service providers, it stresses that these must ensure that

legislation is implemented properly and that all care providers are aware of existing

rights.

‘Understandable’ information

Three approaches (CLAS, COER and EQS) stress that organizations should provide

‘understandable’ information in order to facilitate accessibility. This means providing

information which is translated where necessary and is adapted to the health literacy

level of the targeted populations.

Geographical accessibility

The importance of reducing geographical barriers to accessibility is briefly discussed

in COER and EQS.

Other aspects of accessibility

In EDS and EQS two unique dimensions related to accessibility appeared. Firstly, EDS

mentioned specific types of care (public health, vaccination and screening programs);

secondly, EQS discussed the accessibility of organizations for specific ‘disadvantaged’

target groups such as HIV/AIDS patients, disabled patients, and homeless people.

5. Care provision

Issues in this domain relate to the quality of care patients receive within an

organization. Topics mentioned in the six approaches include: care that is responsive to

the needs and wishes of patients, patient participation in the care process , overcoming

communication barriers, providing ‘understandable’ patient information materials, trust,

and patients’ rights.

Care responsive to needs and wishes

All approaches underline the importance of this issue. The interpretation of this

dimension is related to the different visions the approaches have concerning the nature

of responsive care. ‘Needs’ are discussed in various ways:

- CLAS and CRF focus on the cultural needs of patients, in accordance with their

respective visions on responsive care (‘culturally competent’ and ‘culturally

responsive’).

Chapter 7 121

- JCR refers to ‘additional’ and ‘unique’ needs that should be integrated in the

clinical process: “it is important for hospitals to be prepared to identify and

address not just the clinical aspects of care, but also the spectrum of each

patient’s demographic and personal characteristics”.

- COER focuses on the needs of migrants (broadly defined), going beyond cultural

factors to consider social position, migration history and legal situation.

- EDS and EQS focus on needs resulting from patients’ individual characteristics.

- Apart from identifying needs, JCR also discusses the points in the care

continuum at which they should be taken into account. Although all approaches

emphasize the importance of taking patients’ needs and wishes into account,

they leave it up to the professional to reconcile the demands that patients or

their relatives may make with the dictates of their professional conscience.

Patient participation in the care process

Five approaches (JCR, CRF, COER, EDS) explicitly refer to the importance of patient

participation or involvement in the individual care process, for example in shared

decision making about treatment and care planning (23). CLAS and EQS do not refer

explicitly to patient participation in this context; however, the standards they provide

show that they too consider patients as active participants in their treatment.

Overcoming communication barriers in patient-provider contact

All approaches except EDS emphasize that organizations should systematically tackle

language barriers in the service delivery setting, placing the onus on the organization to

provide patients with language assistance where necessary. Various types of interpreting

are recommended such as professional interpreters, bilingual staff or intercultural

mediators; approaches differ according to which type they prefer. CLAS, JCR and COER

explicitly advise against using untrained, informal interpreters such as family members.

CLAS, JCR, CRF and EQS assert that organizations are responsible for ensuring the quality

and competence of language assistance that is offered. CLAS and JCR mention that

patients should be informed about their right to language assistance. JCR and EQS also

discuss support to patients with other communication barriers (e.g. hearing or speech

impairments).

Understandable patient information materials

With the exception of EDS, all approaches stress that patient information materials

should be understandable for all patients, in terms of both language and level of health

literacy. When suitable materials are not available, CLAS asserts that patients have a

right to orally translated information. These points concern not only patient folders

122 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

providing information about specific medical problems or treatments, but also consent

forms and labeling of medicines.

Trust

The approaches discuss several issues related to building trust between users and

service providers. The first of these is related to the environment within the health care

organization: CLAS, JCR and EQS stress the importance of making this welcoming and

inclusive. Some approaches include statements underlining the security of patients,

stressing that patients should not be exposed to any dangers and mistreatment that

might arise from their vulnerability. Phrases used include “patients are free from abuse,

harassment, bullying, violence” (EDS); and “the patient has the right to be free from

neglect, exploitation, and verbal, mental, physical and sexual abuse” (JC Requirements

(see Box 7.1), p.54 (16)).

A second issue related to trust concerns conflict and grievance procedures. CLAS and

JCR recommend that these procedures should be capable of identifying issues that

concern organizations’ responsiveness to diversity, and that such conflicts should be

dealt with in a respectful manner (CLAS, JCR, and EDS). The issue of access by minority

patients to grievance procedures is also discussed (CLAS, JCR), including the need for

personnel dealing with complaints and grievances to receive proper training (CLAS).

Patients’ rights

CLAS and JCR discuss the importance of informing patients about their rights. This

concerns (among other things) the right in the US to receive language assistance (CLAS,

JCR) and not to experience discrimination (JCR). JCR and EQS also note the importance of

adapting informed consent procedures to the patients’ needs (e.g. health literacy level).

6. Patient and community participation at organizational level

The sixth dimension identified in the approaches concerns the involvement of users

and communities in health care at the organizational level. In this domain one dimension

appeared: involving patients in the development of services. Patient participation in the

care process was not subsumed under this domain.

Involving patients and communities in the development of services

The issue of participation at the organizational level is discussed by all approaches.

The first argument put forward in favor of such participation is that it results in better

responsiveness and quality of care (CLAS, JCR). Another advantage named is that

patients and communities can contribute to the implementation of changes (EDS). The

approaches explicitly (CLAS, CRF, COER, EDS, EQS) or implicitly (JCR) assume that their

target populations often belong to disadvantaged groups that may normally be less likely

Chapter 7 123

to take part in participation processes. The approaches therefore pay attention to the

challenge of creating inclusive participation processes.

Four approaches explicitly mention patient as well as community participation

(CLAS, JCR, CRF, EDS; COER speaks of migrant participation). The important difference

between patient (or user) and community participation is that the latter brings in the

voice of people who did not get into treatment. However, only CLAS and EDS explicitly

regard it as important to build partnerships (e.g. with community representatives or

organizations) in the community served by the health care organization. Their argument

amounts to the following: a health care organization serves a community; therefore the

community has to be enabled to exert influence on what happens in the organization

through a collaborative process. In the other approaches patients and community

members are regarded as complementing each other (usually in the same sentence),

without making clear the additional value of community participation.

7. Promoting responsiveness

Issues were classified in this domain if they concerned the promotion of responsive

health care in the wider society. We identified one dimension, ‘sharing information on

experiences’ in improving care for ethnic minority patients.

Sharing information on experiences

All approaches except CRF mention the importance of sharing experiences in

promoting responsiveness with the general public and the community. This is proposed

with different aims in mind: to increase support for responsive care from the general

public (COER), to demonstrate an organization’s commitment (CLAS, JCR), or to enable

organizations to learn from each other (CLAS, EQS). CRF and EQS take this theme a step

further, by proposing that organizations should enter into active partnerships with

others that promote equity within the health care system (e.g. in research and other

collaborative activities).

8. Unique issues

Two issues were unique to particular approaches. JCR repeatedly mentioned the

identification and addressing of patients’ mobility needs (e.g. using a cane, guide dogs).

EDS emphasized “supporting the workforce to remain healthy”, which is in line with its

focus on equality in the workforce.

‘Vertical’ analysis (comparing approaches)

In the foregoing section we have discussed findings in terms of the domains which

form the rows of the matrix in Table 7.2. In what follows, we analyze differences

124 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

between the approaches represented in the columns, in order to obtain insight into the

specific nature of each approach.

1. As its name implies, CLAS focuses mainly on cultural and linguistic issues. The

linguistic issues have a legal basis in the Civil Rights Act of 1964, which requires “entities

that receive Federal financial assistance to take steps to ensure that limited English

proficient individuals have meaningful access to the health services” (11), p. 10). Issues

related to patients’ position in society are viewed in CLAS as aspects of culture, which is

sometimes confusing. CLAS has a very explicit vision on responsive health care, for

example in the details provided about the content of training or the types of data that

should be collected. Although unequal access is mentioned as a problem which might be

reduced by providing appropriate services, the separate CLAS standards discuss only

linguistic barriers to access.

2. JCR follows the steps in the clinical care process, which is explained by its origin in

the Joint Commission standards for hospitals. JCR was developed as a supplement to

existing standards, so it may have left out some issues already covered by existing Joint

Commission standards. The standards do not embody an elaborated vision on

‘responsiveness’ beyond the general terminology of cultural competence,

communication, and patient- and family-centered care. Accessibility is not

operationalized in JCR. Interestingly, we see that the international branch of the Joint

Commission does consider accessibility as an important aspect of health care: in their

international accreditation standards there is a specific standard on access to care and

continuity of care. For example they have defined the following standard: “the

organization seeks to reduce physical, language, cultural, and other barriers to access

and delivery of services” (p.42 (24)).

3. CRF focuses, like CLAS, mainly on cultural and linguistic issues. Other issues

affecting access to care are not mentioned. CRF offers quantitative and qualitative

indicators (standards and measures) for measuring organizational responsiveness to

diversity. In contrast to other approaches, it offers process indicators. The indicators

provide organizations with relevant information for improving their services, and are also

meant to yield information enabling health services to be compared with each other.

4. COER is at a different level, being addressed to governments rather than

individual health care organizations. Governments are assumed to be ultimately

responsible for everything that goes on in the health system. Issues concerning

organizational responsiveness to diversity are discussed without specifying precisely the

division of responsibilities between levels. In keeping with the Council of Europe’s

historical role, COER is primarily concerned with the ethical and human rights dimensions

of social and health issues.

Chapter 7 125

5. EDS addresses issues concerning both accessibility and quality of care, but its

vision of responsive care for ‘protected groups’ remains rather implicit. The

implementation strategy elaborates on steps such as ‘engage with local interests’ and

‘analyze performance’. The content of responsive care is only briefly described in terms

of goals such as ‘better outcomes for all’ and ‘improved patient access and experience’

(see Table 7.1). EDS does not provide an explicit definition of equality in care or a

specification of how this should be realized in practice.

One of the main objectives of EDS was to provide a tool for NHS commissioners to

comply with the UK’s ‘Public Sector Equality Duty’ (PSED). This is reflected in the

envisaged target groups of EDS (the chosen ‘protected groups’ are the same as those to

which the PSED applies), as well as in the unique focus of EDS on equality among staff

(e.g. equal career changes, no harassment on the work floor) which is in line with the aim

of the PSED to eliminate discrimination and enhance equal opportunities throughout the

public sector. The issue of language is not discussed at all, as it is not discussed in the

PSED. Also unique in EDS is the clear role that has been described for engagement of

patients and communities within the whole implementation strategy.

6. EQS focuses on quality of care and access, which are both aspects of healthcare

equity. Its emphasis is on the vulnerability of certain patients, which can result from

many factors – ‘culture’ being hardly mentioned as one of these. The focus is on patients’

individual needs and characteristics, rather than their membership of specific ethnic,

cultural or other groups. This approach seems to view ‘patient centered care’ as the best

way to respond to diversity in care provision. Although EQS defines its target group as

‘migrants and other vulnerable groups’, most of the standards focus on issues relevant to

migrants, which is explained by the Task Force’s origin in the Migrant Friendly Hospital

network (25).

Variations in the orientation of different approaches

Looking at the differences between approaches, we see that only the European ones

address issues of access to health care in the sense of entitlement. A common feature of

the non-European approaches is their emphasis on ‘culture’. On closer examination, this

seems to be mainly a question of how factors are labeled: sometimes it turns out that

factors such as socioeconomic or legal status are regarded as ‘cultural’ ones. In the

European approaches the issue of culture receives less emphasis: EQS, for example,

hardly mentions it as a topic of importance. Here the focus is on individual

characteristics, which brings EQS close to the approach known as ‘patient centered care’

(26) (Saha, Beach, and Cooper have discussed the relation between ‘patient centered’

and ‘culturally competent’ care (27)). A possible shortcoming of this individualistic

126 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

perspective is that the social position that characterizes members of certain vulnerable

groups (e.g. asylum seekers, irregular migrants) may be overlooked. However, COER and

EQS are the only approaches that explicitly refer to ‘migrants’ and take into account the

vulnerability that results from having different kinds of migrant status (asylum seeker,

irregular migrant, labor migrant etc.).

Discussion and conclusion

Through a qualitative analysis of six current approaches to organizational

responsiveness to the diversity of users, we developed an over-arching framework and

subjected the content of different approaches to a comparative analysis. It emerged that

the following ‘domains’ were almost universally regarded as important for creating

responsive organizations: organizational commitment, collecting data to provide

empirical evidence on inequalities and needs, development of a competent and diverse

workforce, ensuring access for all users, ensuring responsiveness in care provision,

fostering patient and community participation, and actively promoting the ideal of

responsiveness. Almost all these issues could be recognized to some extent in all the

approaches that were analyzed.

With the exception of EDS and EQS, all approaches are primarily oriented to the

needs of ethnic minorities and/or migrants. Differences of language and culture play a

prominent role, especially in CLAS, JCR and CRF. Nevertheless, all approaches recognize

that many aspects of an individual’s social position can give rise to inequalities in health

care. EDS was specifically developed for a wide range of target groups (those covered by

the UK Equality Act). EQS explicitly aimed to address diversity from a broader

perspective; its vision seems heavily influenced by the notion of ‘superdiversity’ (28),

resulting in a strong emphasis on individual differences.

We also analyzed the extent to which the six approaches studied used the same

domains and dimensions. There were relatively few empty cells in the matrices shown in

Tables 2 and 3, which suggests a broad consensus regarding the essential issues. There

were, however, differences regarding the important ingredients of responsive care and

the measures regarded as necessary to improve accessibility. Variations in the

conceptualization of ‘responsive care’ reflect in part different assumptions about the

type of diversity that should be responded to. CLAS and CRF address the issue of racial or

ethnic groups differing in terms of language and/or culture. Patients tend to be identified

as members of a group, with little attention being paid to differences within groups. EDS

and EQS, on the other hand, adopt a more individualistic and multidimensional

approach; though aiming at ‘inclusiveness’, they steer away from definitions of diversity

in terms of group membership. For example, CLAS states that “care should be

Chapter 7 127

compatible with cultural health beliefs and practices, and preferred languages”, whereas

EQS states that “individual characteristics, experiences and living conditions are

considered”. COER is explicitly focused on migrants (broadly defined) as a group, while

mentioning a wide spectrum of issues that may be relevant to the provision of accessible

and appropriate care.

The non-European approaches focus on improving quality of care and improving

linguistic accessibility in the fight against health disparities, while the issue of

‘entitlement to care’ is overlooked. This is remarkable since (lack of) health insurance

coverage explains substantial proportions of disparities in health care in the US (29). The

National Health Interview Study 2012 found that while 7.6% of white respondents had

been uninsured for more than one year, this percentage was 23.6 in the Hispanic

population, 11.7 in the black population, and 11.3 in the Asian population (30). Although

entitlement to care is a matter of health systems, approaches that aim to reduce

disparities in health and health care should at least acknowledge the influence of this

issue on disparities.

Our analysis has its limitations. First of all we based it on six approaches to

organizational responsiveness to diversity. It was not our aim to compare all existing

approaches, because too many have been developed. However, the six approaches that

we included in this framework showed considerable consensus regarding the important

elements of care that is responsive to diversity. The framework can be used to describe

and compare other approaches. Secondly, the level of detail provided by the approaches

varied. Classifying them in our framework might not fully do justice to the visions or

ideas behind the approaches. For example, EDS is very concise in its conceptualization of

responsiveness, but it may be that within the NHS other documents elaborate this

concept in more detail.

Conclusion

To our knowledge this is the first systematic comparison of the content of

approaches for organizational responsiveness to diversity in health care. Our framework

showed that organizational responsiveness to diversity in health care means ensuring

access and providing appropriate care. This in turn is dependent on meeting the

following preconditions: demonstrating organizational commitment, collecting and using

evidence on inequalities and needs, developing a competent and diverse workforce,

fostering patient and community participation, and advocating for responsiveness.

Our analysis shows that there is considerable consensus among approaches

concerning the way in which health service organizations should respond to diversity.

There are differences between the approaches, but many of these do not so much

reflect differences of viewpoint as variations in the emphasis that is placed on the

128 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

concept of ‘culture’. On closer inspection, this variation reflects different definitions of

the concept: in some approaches it is linked to a wide range of attributes such as

socioeconomic position, education, or sexual orientation. This enlarged concept of

culture is particularly pronounced in the Enhanced CLAS Standards (7). However, we

believe that stretching the concept of culture in this way is confusing (31), and the

discussion on providing diversity-responsive health care would win in clarity if the

various social dimensions of importance were clearly distinguished from each other.

The approaches included in the comparison are all to a greater or lesser extent

focused on diversity in migrant and ethnic minority groups. Nevertheless, diversity is a

characteristic of the population as a whole. The focus on responsiveness to diversity

should be extended to all health service users (8). The concept of ‘patient centered care’

is a step in the right direction of acknowledging diversity among all patients. However,

patient centeredness focuses on acknowledging the uniqueness (diversity) of patients,

and is thus individualistic. The most serious inequities in health care are strongly

associated with differences in group membership and social situation. For example,

being an asylum seeker or undocumented migrant is neither a cultural characteristic nor

a personal one – it is a social position, with important consequences for health and

access to health care.

All in all this paper suggests a high degree of agreement between approaches

(countries, institutions) on how health service organizations should respond to diversity.

There is enough consensus in the field to enable us to move ahead in adapting health

services to diversity with the aim of reducing health care inequities. This consensus

creates the opportunity to move forward, to resolve issues regarding terminology and to

help health care organizations to respond to the diversity that is present in modern

societies. At the same time, we need to work as hard as possible to underpin these

recommendations with research.

Tab

le 7

.1 B

ack

gro

un

d in

form

ati

on

on

th

e si

x a

pp

roa

ches

C

LAS

Stan

dar

ds

(CLA

S)

Join

t C

om

mis

sio

n R

oad

map

(JC

R)

Cu

ltu

ral R

esp

on

sive

ne

ss

Fram

ew

ork

(C

RF)

Co

un

cil o

f Eu

rop

e

Re

com

me

nd

atio

ns

(CO

ER)

Equ

alit

y D

eliv

ery

Sys

tem

(ED

S)

Equ

ity

Stan

dar

ds

(EQ

S)

ORIGIN

US

dep

t o

f H

ealt

h a

nd

Hu

man

Ser

vice

s; O

ffic

e o

f

Min

ori

ty h

ealt

h (

U.S

.)

The

Join

t C

om

mis

sio

n (

U.S

.)

Vic

tori

an G

ove

rnm

ent;

Dep

t.

of

Hea

lth

(A

ust

ralia

)

Co

un

cil o

f Eu

rop

e; T

he

com

mit

tee

of

min

iste

rs

(Eu

rop

e)

The

Nat

ion

al H

ealt

h S

ervi

ces

(NH

S); T

he

Equ

alit

y an

d

Div

ersi

ty C

ou

nci

l (U

.K.)

Hea

lth

Pro

mo

tin

g H

osp

ital

s;

Task

Fo

rce

on

Mig

ran

t-

Frie

nd

ly a

nd

Cu

ltu

rally

Co

mp

eten

t H

ealt

h c

are

(Eu

rop

e)

YEAR

20

01

20

10

20

09

20

11

20

11

20

13

AIM

*en

sure

eq

uit

able

an

d

effe

ctiv

e tr

eatm

ent

in a

cult

ura

lly a

nd

lin

guis

tica

lly

app

rop

riat

e m

ann

er

*co

rrec

t in

equ

itie

s

*mo

re r

esp

on

sive

ser

vice

s

*elim

inat

ion

of

raci

al a

nd

eth

nic

hea

lth

dis

par

itie

s

*in

form

, gu

ide

and

fac

ilita

te

cult

ura

lly a

nd

lin

guis

tica

lly

app

rop

riat

e ca

re

*im

pro

ve o

vera

ll sa

fety

an

d

qu

alit

y o

f ca

re

*in

tegr

ate

con

cep

ts f

rom

com

mu

nic

atio

n, c

ult

ura

l

com

pet

ence

an

d p

atie

nt-

cen

tere

d c

are

fiel

ds

into

ho

spit

als

*bet

ter

links

bet

wee

n a

cces

s,

equ

ity,

qu

alit

y an

d s

afet

y

*bet

ter

hea

lth

ou

tco

mes

fo

r

cult

ura

lly a

nd

lin

guis

tica

lly

div

erse

(C

ALD

) p

op

ula

tio

ns

*en

han

ce c

ost

eff

ecti

ven

ess

of

serv

ice

pro

visi

on

*tra

ck o

rgan

izat

ion

s'

imp

rove

men

t; a

lign

cu

ltu

ral

resp

on

sive

nes

s (C

R)

wit

h

exis

tin

g st

and

ard

s; d

evel

op

ben

chm

arks

*eq

uit

able

acc

ess

to h

ealt

h

care

of

app

rop

riat

e q

ual

ity

*bet

ter

ou

tco

mes

fo

r

pat

ien

ts a

nd

co

mm

un

itie

s,

bet

ter

wo

rkin

g en

viro

nm

ents

for

staf

f

*im

pro

ve e

qu

alit

y

per

form

ance

*rev

iew

eq

ual

ity

per

form

ance

*a t

oo

l to

co

mp

ly t

o t

he

‘pu

blic

sec

tor

Equ

alit

y D

uty

’.

*en

sure

eq

uit

able

an

d

acce

ssib

le h

ealt

h c

are

*red

uce

dis

par

ity

in h

ealt

h

care

*an

Eq

uit

y se

lf-a

sses

smen

t

by

hea

lth

car

e o

rgan

izat

ion

s

VISION

*cu

ltu

ral a

nd

lin

guis

tic

com

pet

ence

*cu

ltu

rally

an

d li

ngu

isti

cally

app

rop

riat

e se

rvic

es (

CLA

S)

*eff

ecti

ve c

om

mu

nic

atio

n

(EC

)

*cu

ltu

ral c

om

pet

ence

(C

C)

*pat

ien

t- a

nd

fam

ily-

cen

tere

d c

are

(PFC

C)

*cu

ltu

ral r

esp

on

sive

nes

s (C

R)

*im

pro

vin

g th

e ad

apta

tio

n o

f

hea

lth

ser

vice

pro

visi

on

to

the

nee

ds,

cu

ltu

re a

nd

so

cial

situ

atio

n o

f m

igra

nts

*eq

ual

ity

for

pat

ien

ts a

nd

staf

f

*per

son

al, f

air

and

div

ers

e

serv

ices

an

d w

ork

pla

ces

*pro

mo

tin

g eq

uit

y

TARGET POPULATION

*in

clu

sive

of

all p

atie

nts

*esp

ecia

lly r

acia

l, et

hn

ic, a

nd

lingu

isti

c p

op

ula

tio

ns

that

exp

erie

nce

un

equ

al a

cces

s

*no

tar

get

gro

up

,

reco

mm

end

atio

ns

add

ress

'issu

es' i

n h

ealt

h c

are

(e.g

.

lan

guag

e, c

ult

ure

etc

.)

*cu

ltu

rally

an

d li

ngu

isti

cally

div

erse

po

pu

lati

on

s (C

ALD

)

*mig

ran

ts

*pro

tect

ed g

rou

ps

*mig

ran

ts a

nd

all

oth

er

vuln

erab

le g

rou

ps

C

LAS

Stan

dar

ds

(CLA

S)

Join

t C

om

mis

sio

n R

oad

map

(JC

R)

Cu

ltu

ral R

esp

on

sive

ne

ss

Fram

ew

ork

(C

RF)

Co

un

cil o

f Eu

rop

e

Re

com

me

nd

atio

ns

(CO

ER)

Equ

alit

y D

eliv

ery

Sys

tem

(ED

S)

Equ

ity

Stan

dar

ds

(EQ

S)

TARGET ORGANIZATION-TYPE

*hea

lth

car

e o

rgan

izat

ion

s

*po

licym

aker

s, a

ccre

dit

atio

n

agen

cies

, pu

rch

aser

s,

pat

ien

ts, a

dvo

cate

s,

edu

cato

rs, h

ealt

h c

are

com

mu

nit

y in

gen

eral

*ho

spit

als

*a

ll V

icto

rian

hea

lth

se

rvic

es

*go

vern

men

ts o

f C

oE

mem

ber

sta

tes

*NH

S co

mm

issi

on

ers

and

pro

vid

ers

*hea

lth

car

e o

rgan

izat

ion

s

STRUCTURE

*14

sta

nd

ard

s in

th

ree

typ

es:

man

dat

es (

4),

gu

idel

ines

(9

),

and

rec

om

men

dat

ion

s (1

)

*3 t

hem

es: c

ult

ura

lly

com

pet

ent

care

, lan

guag

e

acce

ss s

ervi

ces,

an

d

org

aniz

atio

nal

su

pp

ort

s fo

r

cult

ura

l co

mp

eten

ce

*54

rec

om

men

dat

ion

s

stru

ctu

red

aro

un

d m

ain

po

ints

alo

ng

the

care

con

tin

uu

m

*asp

ects

of

the

care

con

tin

uu

m: a

dm

issi

on

;

asse

ssm

ent;

tre

atm

ent;

en

d

of

life

care

; dis

char

ge a

nd

tran

sfer

; org

aniz

atio

n

read

ines

s

*6 s

tan

dar

ds

acro

ss f

ou

r

do

mai

ns,

div

ided

in

mea

sure

s an

d s

ub

-mea

sure

s

(bo

th q

uan

tita

tive

an

d

qu

alit

ativ

e)

*Sta

nd

ard

s: a

wh

ole

org

aniz

atio

n a

pp

roac

h;

lead

ersh

ip;

inte

rpre

ters

;

incl

usi

ve p

ract

ice;

con

sum

er/c

om

mu

nit

y

invo

lvem

ent;

sta

ff.

*4 d

om

ain

s: o

rgan

izat

ion

al

effe

ctiv

enes

s; r

isk

man

agem

ent;

co

nsu

mer

par

tici

pat

ion

; eff

ecti

ve

wo

rkfo

rce

*14

rec

om

men

dat

ion

s,

spec

ifie

d in

31

su

b-

reco

mm

end

atio

ns.

*18

ou

tco

mes

gro

up

ed in

to

fou

r go

als;

nin

e st

eps

for

imp

lem

enta

tio

n

*ED

S go

als:

bet

ter

hea

lth

ou

tco

mes

fo

r al

l; im

pro

ved

pat

ien

t ac

cess

an

d

exp

erie

nce

; em

po

wer

ed,

enga

ged

, an

d w

ell-

sup

po

rted

staf

f; in

clu

sive

lead

ersh

ip a

t

all l

eve

ls

*5 m

ain

sta

nd

ard

s, d

ivid

ed in

sub

sta

nd

ard

s an

d

mea

sura

ble

ele

men

ts

*mai

n s

tan

dar

ds:

eq

uit

y in

po

licy;

eq

uit

able

acc

ess

and

uti

lizat

ion

; eq

uit

able

qu

alit

y

of

care

; eq

uit

y in

par

tici

pat

ion

; pro

mo

tin

g

equ

ity

Tab

le 7

.2 T

he

ap

pro

ach

es in

sert

ed in

th

e a

na

lyti

c fr

am

ewo

rk

DO

MA

INS

&

dim

en

sio

ns

CLA

S JC

R

CR

F C

OER

ED

S EQ

S

OR

GA

NIZ

ATI

ON

AL

CO

MM

ITM

ENT

Policy and leadership

*a w

ritt

en s

trat

egic

pla

n t

o

pro

vid

e cu

ltu

rally

com

pet

ent

care

*str

ateg

ic p

lan

is in

tegr

ally

tied

to

th

e o

rgan

izat

ion

's

mis

sio

n, p

rin

cip

les,

ser

vice

focu

s

*dem

on

stra

te le

ader

ship

com

mit

men

t to

eff

ecti

ve

com

mu

nic

atio

n (

EC),

cult

ura

l co

mp

eten

ce (

CC

),

and

pat

ien

t- a

nd

fam

ily

cen

tere

d c

are

(PFC

C)

*in

tegr

ate

con

cep

ts o

f EC

,

CC

, PFC

C in

to e

xist

ing

po

licie

s

*im

ple

men

t a

Cu

ltu

ral

Res

po

nsi

ven

ess

(CR

)-p

lan

add

ress

ing

the

stan

dar

ds

*in

tegr

ate

CR

-pla

n in

to

exis

tin

g se

rvic

es’ p

lan

s an

d

pro

cess

es

*dem

on

stra

te le

ader

ship

*hav

e an

ad

visi

ng

stru

ctu

re

wit

h p

arti

cip

atio

n o

f

cult

ura

lly a

nd

lin

guis

tica

lly

div

erse

(C

ALD

) p

op

ula

tio

ns

*allo

cati

on

of

fin

anci

al

reso

urc

es

*em

plo

y a

cult

ura

l div

ers

ity

staf

f m

emb

er w

hen

CA

LD

po

pu

lati

on

> 2

0%

*org

aniz

atio

n a

s a

wh

ole

mu

st b

e ‘c

ult

ura

lly

com

pet

ent’

*im

ple

men

t th

e

reco

mm

end

atio

ns

in a

sust

ain

able

, co

ord

inat

ed

and

evi

den

ce b

ased

way

*lea

der

s co

nd

uct

an

d p

lan

bu

sin

ess

so t

hat

eq

ual

ity

is

adva

nce

d

*man

ager

s su

pp

ort

an

d

mo

tiva

te s

taff

to

wo

rk

cult

ura

lly c

om

pet

ent

*rec

ruit

, dev

elo

p a

nd

sup

po

rt s

trat

egic

lead

ers

to

adva

nce

eq

ual

ity

ou

tco

mes

*in

tegr

ate

equ

alit

y

ob

ject

ive

s in

to m

ain

stre

am

bu

sin

ess

pla

nn

ing

*a s

pec

ific

pla

n t

o p

rom

ote

equ

ity,

inte

grat

ed w

ith

exis

tin

g ac

cou

nta

bili

ty

syst

ems

*all

org

aniz

atio

n p

lan

s

pro

mo

te e

qu

ity

Measuring and improving performance

*in

itia

l an

d o

n-g

oin

g se

lf-

asse

ssm

ent

of

CLA

S-re

late

d

care

*in

tegr

ate

CLA

S-re

late

d

mea

sure

s in

to r

egu

lar

qu

alit

y im

pro

vem

ent

pro

gram

s (e

.g. i

nte

rnal

aud

its)

*use

dat

a o

n in

div

idu

al

pat

ien

ts f

or

nee

ds

asse

ssm

ent,

ser

vice

pla

nn

ing

and

qu

alit

y

imp

rove

men

t

*a b

asel

ine

asse

ssm

ent

wh

eth

er o

rgan

izat

ion

mee

ts

un

iqu

e p

atie

nt

nee

ds

*ob

ligat

ory

rep

ort

ing

on

CR

per

form

ance

(o

n d

efin

ed

mea

sure

s)

*per

form

res

earc

h in

ou

tco

mes

(e.

g. e

mer

gen

cy

pre

sen

tati

on

s) f

or

CA

LD

pat

ien

ts’ c

are

nee

ds

*an

alyz

e q

ual

ity/

risk

man

agem

ent

dat

a fo

r C

ALD

pat

ien

ts

*rep

ort

on

CR

per

form

ance

in o

rgan

izat

ion

's r

egu

lar

per

form

ance

rep

ort

s

*in

clu

de

CA

LD s

take

ho

lder

s

in p

erfo

rman

ce r

evie

w

*eva

luat

e ex

isti

ng

serv

ices

,

iden

tify

exi

stin

g p

rob

lem

s,

dev

elo

p g

oo

d p

ract

ices

*co

nd

uct

res

earc

h t

o

iden

tify

pro

ble

ms,

det

erm

ine

acti

on

s an

d

eval

uat

e in

terv

enti

on

s

*an

alyz

e p

erf

orm

ance

,

agre

e (w

ith

sta

keh

old

ers)

on

resu

lts,

an

d p

rep

are

equ

alit

y

ob

ject

ive

s

*co

nti

nu

ally

iden

tify

an

d

mo

nit

or

acce

ss a

nd

bar

rie

rs

in a

cces

s, a

nd

eva

luat

e

inte

rven

tio

ns

for

red

uci

ng

acce

ss b

arri

ers

(e.g

.

com

mu

nic

atio

n s

up

po

rt

serv

ices

)

*use

dat

a o

n e

qu

ity

per

form

ance

to

imp

rove

equ

ity

in a

cces

sib

ility

an

d

qu

alit

y

DO

MA

INS

&

dim

en

sio

ns

CLA

S JC

R

CR

F C

OER

ED

S EQ

S

CO

LLEC

TIN

G D

ATA

Data on the population at

large *m

ain

tain

a c

urr

ent

dem

ogr

aph

ic, c

ult

ura

l an

d

epid

emio

logi

cal p

rofi

le, a

nd

a n

eed

s as

sess

men

t o

f th

e

com

mu

nit

y

*use

ava

ilab

le p

op

ula

tio

n-

leve

l dem

ogr

aph

ic d

ata

of

surr

ou

nd

ing

com

mu

nit

y

*mo

nit

or

com

mu

nit

y p

rofi

le

and

dem

ogr

aph

ics

*go

vern

men

ts (

in

par

tner

ship

wit

h o

ther

rele

van

t o

rgan

izat

ion

s)

colle

ct b

ackg

rou

nd

dat

a an

d

epid

emio

logi

cal d

ata

on

mig

ran

ts

*ass

emb

le e

vid

ence

dra

win

g

on

exi

stin

g in

form

atio

n

syst

ems

(in

cl d

ata

on

po

pu

lati

on

leve

l)

*co

llect

or

hav

e ac

cess

to

dat

a o

n h

ealt

h s

tatu

s an

d

hea

lth

ineq

ual

itie

s o

f

catc

hm

ent

area

Data on the patient population

*co

llect

dat

a o

n in

div

idu

al

pat

ien

t's

race

, eth

nic

ity,

spo

ken

/wri

tten

lan

guag

e in

hea

lth

rec

ord

*in

tegr

ate

CLA

S-re

late

d

mea

sure

s in

to p

atie

nt

sati

sfac

tio

n a

sses

smen

ts

*dev

elo

p a

sys

tem

to

co

llect

pat

ien

t-le

vel d

ata

*co

llect

dat

a o

n p

atie

nt

race

and

eth

nic

ity

in m

edic

al

reco

rd

*co

llect

dat

a o

n p

atie

nt'

s

lan

guag

e an

d a

dd

itio

nal

pat

ien

t-le

vel i

nfo

rmat

ion

(e.g

. cu

ltu

ral,

relig

iou

s)

*co

llect

fe

edb

ack

fro

m

pat

ien

ts, f

amili

es

*dev

elo

p a

pp

rop

riat

e

info

rmat

ion

str

ateg

ies

for

dat

a co

llect

ion

, rep

ort

ing

and

sh

arin

g

*co

llect

CA

LD p

atie

nt

sati

sfac

tio

n d

ata

*a

ssem

ble

evi

den

ce

incl

ud

ing

surv

eys

of

pat

ien

t

exp

erie

nce

s

*org

aniz

atio

n's

sys

tem

s ca

n

mea

sure

eq

uit

y

per

form

ance

*id

enti

fy p

atie

nts

' nee

ds

acco

rdin

g to

ch

arac

teri

stic

s

(hea

lth

rec

ord

s in

clu

de

info

rmat

ion

on

dem

ogr

aph

ic

char

acte

rist

ics

e.g.

lan

guag

e,

hea

lth

lite

racy

leve

l,

eth

nic

ity)

STA

FF/W

OR

KFO

RC

E

Staff competencies

*all

staf

f re

ceiv

e o

n-g

oin

g

edu

cati

on

in p

rovi

din

g C

LAS

*new

an

d e

xist

ing

trai

nin

g

add

ress

es is

sues

of

EC, C

C,

PFC

C

*pro

vid

e st

aff

at a

ll le

vels

wit

h o

pp

ort

un

itie

s to

enh

ance

th

eir

CR

*tra

in s

taff

*CR

ref

eren

ces

incl

ud

ed in

HR

M p

olic

ies

and

pra

ctic

es

(e.g

. po

siti

on

des

crip

tio

n)

*co

mm

un

icat

ion

sys

tem

s

for

shar

ing

info

rmat

ion

on

CR

*car

e p

rofe

ssio

nal

s at

vari

ou

s le

vels

sh

ou

ld b

e

trai

ned

in a

cces

sib

ility

issu

es

and

in c

ult

ura

l co

mp

eten

ce

*en

able

sta

ff t

o b

e

con

fid

ent

and

pro

vid

e

app

rop

riat

e ca

re w

ith

sup

po

rt b

y tr

ain

ing,

per

son

al d

evel

op

men

t an

d

per

form

ance

ap

pra

isal

*all

staf

f is

aw

are

and

com

pet

ent

to a

dd

ress

ineq

uit

ies

du

e to

ed

uca

tio

n

*sp

ecif

ic t

rain

ing

on

eq

uit

y

issu

es

*in

clu

de

equ

ity

issu

es in

org

aniz

atio

n's

co

re

edu

cati

on

DO

MA

INS

&

dim

en

sio

ns

CLA

S JC

R

CR

F C

OER

ED

S EQ

S

Diversity in workforce *s

trat

egie

s to

rec

ruit

, ret

ain

and

pro

mo

te d

iver

se s

taff

,

rep

rese

nta

tive

of

dem

ogr

aph

ic c

har

acte

rist

ics

of

serv

ice

area

*div

erse

sta

ff a

t al

l lev

els

,

incl

ud

ing

div

ers

e le

ade

rsh

ip

*rec

ruit

men

t ef

fort

s to

incr

ease

a d

iver

se w

ork

forc

e

that

ref

lect

s th

e p

atie

nt

po

pu

lati

on

*div

erse

wo

rkfo

rce

can

incr

ease

eth

nic

an

d

lan

guag

e co

nco

rdan

ce,

wh

ich

may

imp

rove

com

mu

nic

atio

n

*r

ecru

itm

ent

po

licie

s sh

ou

ld

ensu

re t

hat

th

e d

iver

sity

of

gen

eral

po

pu

lati

on

is

refl

ecte

d in

th

e w

ork

forc

e

(men

tio

ned

as

an

exa

mp

le)

*fai

r se

lect

ion

pro

cess

es t

o

incr

ease

div

ersi

ty o

f al

l

wo

rkfo

rce

*eq

ual

ity

in le

vels

of

pay

*sta

ff c

an w

ork

in a

saf

e

envi

ron

men

t (e

.g. f

ree

fro

m

abu

se, h

aras

smen

t et

c.)

*fle

xib

le w

ork

ing

op

tio

ns

*fai

r an

d e

qu

itab

le

wo

rkfo

rce

po

licie

s an

d

pra

ctic

es

*pro

mo

te r

esp

ect

fo

r d

ign

ity

of

all s

taff

an

d v

olu

nte

ers

ENSU

RIN

G A

CC

ESS

Entitlement to care

*l

egis

lati

on

co

nce

rnin

g

enti

tlem

ent

is p

rop

erly

imp

lem

ente

d

*pro

fess

ion

als

at a

ll le

vels

are

awar

e o

f e

ligib

ility

rig

hts

*m

on

ito

r si

tuat

ion

s o

f

peo

ple

th

at a

re in

elig

ible

fo

r

care

*en

sure

hea

lth

car

e to

peo

ple

ine

ligib

le f

or

serv

ices

by

pro

vid

ing

app

rop

riat

e

sup

po

rt

'Understandable' information

*pat

ien

t re

late

d m

ater

ials

and

po

st s

ign

age

esse

nti

al

for

acce

ss s

ho

uld

be

mad

e

easi

ly u

nd

ers

too

d

*off

er a

nd

pro

vid

e la

ngu

age

assi

stan

ce s

erv

ice

s to

all

pat

ien

ts w

ith

LEP

, at

all

con

tact

s, in

a t

imel

y m

ann

er

du

rin

g al

l ho

urs

of

op

erat

ion

*pro

gram

s fo

r m

igra

nts

sho

uld

incl

ud

e kn

ow

led

ge

on

hea

lth

an

d il

lnes

s, t

he

way

th

e h

ealt

h s

yste

m

wo

rks,

an

d e

nti

tlem

ents

to

hea

lth

ser

vice

s

*pro

mo

te in

terp

reta

tio

n

and

tra

nsl

ated

mat

eria

ls t

o

imp

rove

acc

essi

bili

ty

*i

n c

om

mu

nic

atin

g w

ith

peo

ple

an

d p

rovi

din

g

info

rmat

ion

on

acc

ess

issu

es, h

ealt

h li

tera

cy a

nd

lan

guag

e n

eed

s ar

e ta

ken

into

acc

ou

nt

Geographical accessibility

*i

nco

nve

nie

nt

loca

tio

ns

sho

uld

be

red

uce

d a

s fa

r as

po

ssib

le

*m

inim

ize

arch

ite

ctu

ral,

envi

ron

men

tal a

nd

geo

grap

hic

al b

arri

ers

to

faci

litie

s

DO

MA

INS

&

dim

en

sio

ns

CLA

S JC

R

CR

F C

OER

ED

S EQ

S Other aspects of

accessibility

*rem

ove

acc

essi

bili

ty

bar

rier

s an

d r

edu

ce p

ract

ical

dif

ficu

ltie

s (e

.g.

inco

nve

nie

nt

op

enin

g ti

mes

)

*pat

ien

ts, c

arer

s an

d

com

mu

nit

ies

can

rea

dily

acce

ss s

ervi

ces

*pu

blic

hea

lth

, vac

cin

atio

n

and

scr

een

ing

pro

gram

s

ben

efit

all

loca

l

com

mu

nit

ies/

gro

up

s

*en

sure

acc

ess

to

car

e fo

r

dis

adva

nta

ged

peo

ple

*pro

vid

e o

utr

each

info

rmat

ion

to

dis

adva

nta

ged

peo

ple

on

ou

trea

ch s

erv

ice

s

CA

RE

PR

OV

ISIO

N

Care responsive to needs and wishes

*pat

ien

ts r

ece

ive

effe

ctiv

e

(po

siti

ve o

utc

om

es),

un

der

stan

dab

le a

nd

resp

ectf

ul (

pat

ien

ts v

alu

es

take

n in

to a

cco

un

t) c

are

*car

e sh

ou

ld b

e co

mp

atib

le

wit

h c

ult

ura

l hea

lth

bel

iefs

and

pra

ctic

es,

an

d p

refe

rred

lan

guag

es

Thro

ugh

ou

t th

e ca

re

con

tin

uu

m:

*ask

fo

r ad

dit

ion

al n

eed

s

(e.g

. cu

ltu

ral,

relig

iou

s)

*co

mm

un

icat

e in

form

atio

n

abo

ut

un

iqu

e p

atie

nt

nee

ds

to r

ele

van

t p

rovi

der

s

*sta

rt p

atie

nt-

pro

vid

er

inte

ract

ion

wit

h a

n

intr

od

uct

ion

*id

enti

fy a

nd

acc

om

mo

dat

e

cult

ura

l, re

ligio

us,

sp

irit

ual

bel

iefs

/pra

ctic

es t

hat

infl

uen

ce c

are

*in

corp

ora

te E

C, C

C, P

FCC

con

cep

ts in

to c

are

del

iver

y

*in

clu

sive

pra

ctic

e in

car

e

pla

nn

ing

(in

clu

din

g d

ieta

ry,

spir

itu

al a

nd

oth

er

cult

ura

l

pra

ctic

es)

*im

ple

men

tati

on

an

d

revi

sio

n o

f p

olic

ies

for

pro

visi

on

of

app

rop

riat

e

mea

ls

*use

fee

db

ack/

eval

uat

ion

fro

m p

atie

nts

to

imp

rove

CR

*dev

elo

p a

nd

use

su

itab

le

inst

rum

ents

fo

r as

sess

men

t

(e.g

. clin

ical

dia

gno

sis)

wh

ich

inco

rpo

rate

cu

ltu

ral

con

sid

erat

ion

s

*im

pro

ve r

ele

van

ce a

nd

app

rop

riat

enes

s o

f h

ealt

h

serv

ices

*off

erin

g th

e sa

me

serv

ices

to e

very

bo

dy

may

res

ult

in

use

rs r

ece

ivin

g lo

wer

qu

alit

y

of

care

*ser

vice

s sh

ou

ld b

e

cult

ura

lly c

om

pet

ent

(mat

ched

to

nee

ds

of

mig

ran

ts f

rom

div

erse

bac

kgro

un

ds)

*cu

ltu

rally

co

mp

eten

t ca

re

goes

bey

on

d c

ult

ura

l

fact

ors

, e.g

. so

cial

po

siti

on

,

his

tory

, leg

al s

itu

atio

n

sho

uld

als

o b

e t

aken

into

acco

un

t

*ad

apt

exis

tin

g d

iagn

ost

ic

and

th

erap

euti

c p

roce

du

res

or

inve

nt

new

on

es if

nec

essa

ry

*ass

ess

ind

ivid

ual

pat

ien

ts'

hea

lth

nee

ds

and

pro

vid

e

app

rop

riat

e an

d e

ffec

tive

serv

ices

*dis

cuss

ch

ange

s ac

ross

serv

ices

wit

h p

atie

nts

an

d

mak

e tr

ansi

tio

ns

smo

oth

ly

*str

ive

fo

r p

osi

tive

trea

tmen

t ex

per

ien

ces:

bei

ng

liste

ned

to

, bei

ng

resp

ecte

d, p

riva

cy a

nd

dig

nit

y ar

e p

rio

riti

zed

*in

nee

ds

asse

ssm

ents

,

del

iver

y o

f ca

re a

nd

at

dis

char

ge, p

atie

nts

’

ind

ivid

ual

, fam

ily

char

acte

rist

ics,

exp

erie

nce

s

and

livi

ng

con

dit

ion

s ar

e

take

n in

to a

cco

un

t (i

ncl

.

psy

cho

soci

al n

eed

s)

*wo

rkfo

rce

is a

ble

to

tak

e

into

acc

ou

nt

ind

ivid

ual

pat

ien

ts' i

dea

s an

d

exp

erie

nce

s o

f h

ealt

h a

nd

illn

ess

in c

linic

al p

ract

ice

and

at d

isch

arge

*car

e is

co

nsi

der

ate

and

resp

ectf

ul o

f p

atie

nts

'

dig

nit

y, p

erso

nal

val

ues

,

kno

wle

dge

an

d b

elie

fs

rega

rdin

g h

ealt

h c

are

DO

MA

INS

&

dim

en

sio

ns

CLA

S JC

R

CR

F C

OER

ED

S EQ

S Patient

participation in the care

process

*I

nvo

lve

pat

ien

ts, f

amili

es,

sup

po

rt p

erso

ns

in t

he

care

pro

cess

alo

ng

the

car

e

con

tin

uu

m.

*in

clu

sive

pra

ctic

e in

car

e

pla

nn

ing

(in

clu

din

g d

ieta

ry,

spir

itu

al a

nd

oth

er

cult

ura

l

pra

ctic

es)

*pro

mo

te p

arti

cip

atio

n o

f

mig

ran

ts in

all

acti

viti

es

con

cern

ing

the

pro

visi

on

of

hea

lth

ser

vice

s, in

clu

din

g

dec

isio

n m

akin

g p

roce

sses

*in

volv

e p

atie

nts

as

the

y

wis

h d

uri

ng

the

care

con

tin

uu

m

Overcoming communication barriers in patient-provider

contact

*off

er a

nd

pro

vid

e la

ngu

age

assi

stan

ce s

erv

ice

s

(in

clu

din

g b

ilin

gual

sta

ff,

inte

rpre

ter

serv

ices

) at

no

cost

s to

all

pat

ien

ts w

ith

LEP

, at

all c

on

tact

s, in

a

tim

ely

man

ner

du

rin

g al

l

ho

urs

of

op

erat

ion

*in

form

pat

ien

ts o

f th

eir

righ

t to

re

ceiv

e la

ngu

age

assi

stan

ce

*ass

ure

co

mp

eten

ce o

f

lan

guag

e as

sist

ance

by

inte

rpre

ters

an

d b

ilin

gual

staf

f

*id

enti

fy p

atie

nt'

s p

refe

rred

lan

guag

e o

r o

ther

com

mu

nic

atio

n n

eed

s

du

rin

g ad

mis

sio

n

*id

enti

fy a

nd

mo

nit

or

pat

ien

t co

mm

un

icat

ion

nee

ds/

stat

us

du

rin

g ca

re

con

tin

uu

m, d

ocu

men

t th

is

in p

atie

nt

reco

rd

*en

sure

co

mp

eten

ce o

f

lan

guag

e as

sist

ance

*dev

elo

p a

sys

tem

to

pro

vid

e la

ngu

age

serv

ices

*in

form

pat

ien

ts o

f th

eir

righ

ts f

or

an in

terp

rete

r

*im

ple

men

t la

ngu

age

serv

ices

po

licy

*po

licie

s in

clu

de

dir

ecti

on

s

abo

ut

role

of

inte

rpre

ters

and

fam

ily

*pro

vid

e ac

cred

ited

inte

rpre

ters

to

pat

ien

ts w

ho

nee

d o

ne

*mat

ch e

mp

loym

ent

of

in-

ho

use

inte

rpre

ters

to

com

mu

nit

y d

emo

grap

hic

s

*eva

luat

e in

terp

rete

r

serv

ices

*hig

h q

ual

ity

inte

rpre

tin

g

sho

uld

be

pro

mo

ted

*co

nsi

der

all

avai

lab

le

met

ho

ds

to r

edu

ce la

ngu

age

bar

rier

s

*h

ave

a p

olic

y o

n

ove

rco

min

g la

ngu

age

bar

rier

s

*mak

e p

rofe

ssio

nal

inte

rpre

tin

g se

rvic

es

avai

lab

le a

nd

pro

mo

te it

*acc

om

mo

dat

e

com

mu

nic

atio

n n

eed

s o

f

pat

ien

ts w

ith

e.g

. hea

rin

g,

spee

ch im

pai

rmen

ts

*mo

nit

or

qu

alit

y o

f

inte

rpre

tin

g se

rvic

es/

com

mu

nic

atio

n s

up

po

rt

*en

sure

sta

ff a

bili

ty t

o w

ork

wit

h in

terp

rete

r/

com

mu

nic

atio

n s

up

po

rt

staf

f

DO

MA

INS

&

dim

en

sio

ns

CLA

S JC

R

CR

F C

OER

ED

S EQ

S

'Understandable' patient information materials *p

rovi

de

easi

ly u

nd

erst

oo

d

pat

ien

t re

late

d m

ater

ials

(ap

plic

atio

ns,

co

nse

nt

form

s) a

nd

po

st s

ign

age

in

div

erse

lan

guag

es in

cl.

dir

ecti

on

s to

fac

ility

ser

vice

s

(div

erse

lan

gu

ag

e:

lan

gu

ag

es o

f co

mm

on

ly

enco

un

tere

d g

rou

ps/

gro

up

s

rep

rese

nte

d in

th

e se

rvic

e

are

a)

*tak

e in

to a

cco

un

t cu

ltu

re

and

hea

lth

lite

racy

leve

ls

*per

son

s fr

om

sm

all

lan

guag

e gr

ou

ps

hav

e th

e

righ

t to

ora

l tra

nsl

atio

n

*pro

vid

e p

atie

nt

edu

cati

on

mat

eria

ls a

nd

inst

ruct

ion

s

that

mee

t p

atie

nts

' nee

ds

(hea

lth

lite

racy

, lan

guag

e)

du

rin

g as

sess

men

t,

trea

tmen

t an

d d

isch

arge

*su

pp

ort

pat

ien

t’s

abili

ty t

o

un

der

stan

d/a

ct o

n h

ealt

h

info

rmat

ion

*det

erm

ine

nee

ds

for

assi

stan

ce w

ith

ad

mis

sio

n

form

s (h

ealt

h li

tera

cy)

*hav

e ap

pro

pri

ate

tran

slat

ion

s o

f si

gnag

e,

pat

ien

t fo

rms,

ed

uca

tio

n

mat

eria

ls f

or

pre

do

min

ant

lan

guag

e gr

ou

ps

usi

ng

serv

ices

*pro

mo

te h

igh

qu

alit

y

tran

slat

ed w

ritt

en

info

rmat

ion

*p

rovi

de

easi

ly u

nd

erst

oo

d

wri

tten

mat

eria

l an

d s

ign

age

taki

ng

hea

lth

lite

racy

an

d

lan

guag

e n

eed

s in

to a

cco

un

t

Trust

Co

nfl

ict

& g

riev

an

ce

*co

nfl

ict/

grie

van

ce

pro

ced

ure

s ar

e cu

ltu

rally

sen

siti

ve

*co

nfl

ict/

grie

van

ce

pro

ced

ure

s ca

n id

enti

fy,

pre

ven

t, r

eso

lve

cro

ss-

cult

ura

l co

nfl

icts

/co

mp

lain

ts

*sta

ff h

and

ling

com

pla

ints

sho

uld

rec

eiv

e cu

ltu

ral

com

pet

ence

tra

inin

g

*mo

nit

or

cult

ura

lly o

r

lingu

isti

cally

re

late

d

com

pla

ints

Atm

osp

her

e

*cre

ate

a w

elco

min

g an

d

incl

usi

ve e

nvi

ron

men

t

Co

nfl

ict

& g

riev

an

ce

*acc

essi

ble

co

mp

lain

ts

syst

em (

lan

guag

e, n

on

-

wri

tin

g)

*co

mp

lain

ts a

re n

ot

bei

ng

sub

ject

ed t

o c

oer

cio

n,

dis

crim

inat

ion

, rep

risa

l, o

r

un

reas

on

able

inte

rru

pti

on

of

care

Atm

osp

her

e

*cre

ate

an e

nvi

ron

men

t th

at

is in

clu

sive

of

all p

atie

nts

*pat

ien

t h

as t

he

righ

t to

be

free

of

neg

lect

, exp

loit

atio

n

and

ab

use

(re

gu

lar

JC

sta

nd

ard

s, c

ha

pte

r: R

igh

ts

an

d R

esp

on

sib

iliti

es o

f th

e

Ind

ivid

ua

l)

Co

nfl

ict

& g

riev

an

ce

*mo

nit

or

nu

mb

er o

f

com

pla

ints

lod

ged

by

CA

LD

con

sum

ers/

pat

ien

ts.

C

on

flic

t &

gri

eva

nce

*co

mp

lain

ts s

ho

uld

be

han

dle

d r

esp

ectf

ully

an

d

effi

cien

tly

Atm

osp

her

e

*cre

ate

a sa

fe e

nvi

ron

men

t,

wit

ho

ut

thre

at o

f d

ign

ity

of

den

ial o

f in

div

idu

al id

enti

ty

Atm

osp

her

e

*cre

ate

a sa

fe e

nvi

ron

men

t,

wit

h r

esp

ect

for

pat

ien

t's

dig

nit

y an

d id

enti

ty

*cre

ate

an e

nvi

ron

men

t

incl

usi

ve f

or

all p

atie

nts

DO

MA

INS

&

dim

en

sio

ns

CLA

S JC

R

CR

F C

OER

ED

S EQ

S

Patients' rights *p

rovi

de

no

tice

s in

div

erse

lan

guag

e o

f a

vari

ety

of

pat

ien

ts’ r

igh

ts (

incl

ud

ing

righ

t fo

r la

ngu

age

assi

stan

ce)

*in

form

pat

ien

ts o

f th

eir

righ

ts (

inte

rpre

ter,

acco

mm

od

atio

n f

or

dis

abili

ty, b

e fr

ee f

rom

dis

crim

inat

ion

, etc

.)

*tai

lor

the

info

rmed

co

nse

nt

pro

cess

to

mee

t p

atie

nt

nee

ds

(rel

ated

to

low

HL)

*a

cco

mm

od

ate

pat

ien

ts'

div

erse

ne

eds

in in

form

ed

con

sen

t p

roce

du

re

PA

TIEN

T A

ND

CO

MM

UN

ITY

PA

RTI

CIP

ATI

ON

AT

OR

GA

NIZ

ATI

ON

AL

LEV

EL

Involving patients and communities in the

development of services

*uti

lize

a va

riet

y

mec

han

ism

s to

fac

ilita

te

com

mu

nit

y an

d p

atie

nt

invo

lvem

ent

in d

esig

nin

g

and

imp

lem

enti

ng

serv

ices

*dev

elo

p p

arti

cip

ato

ry,

colla

bo

rati

ve p

artn

ersh

ips

wit

h c

om

mu

nit

ies

*be

invo

lved

an

d e

nga

ged

wit

h p

atie

nts

, fam

ilies

an

d

the

com

mu

nit

y to

ide

nti

fy

nee

ds

for

new

/mo

dif

ied

serv

ices

*co

llect

fe

edb

ack

fro

m

pat

ien

t, f

amili

es

and

com

mu

nit

ies

*CA

LD c

on

sum

er, c

arer

an

d

com

mu

nit

y m

emb

ers

are

invo

lved

in t

he

pla

nn

ing,

imp

rove

men

t an

d r

evie

w o

f

pro

gram

s an

d s

ervi

ces

on

an

on

-go

ing

bas

is

*ad

vice

of

par

tici

pat

ion

stru

ctu

res

is t

aken

into

acco

un

t

*fac

ilita

te d

iffe

ren

t d

egre

es

of

par

tici

pat

ion

fro

m C

ALD

con

sum

ers,

car

ers,

com

mu

nit

y

*dev

elo

p p

artn

ersh

ips

wit

h

eth

no

-sp

ecif

ic c

om

mu

nit

y

org

aniz

atio

ns

*pro

mo

te p

arti

cip

atio

n o

f

mig

ran

ts in

des

ign

ing,

eval

uat

ing,

an

d c

arry

ing

ou

t

rese

arch

on

mig

ran

t h

ealt

h

and

hea

lth

car

e

*pro

mo

te p

arti

cip

atio

n o

f

mig

ran

ts in

dev

elo

pin

g an

d

imp

lem

enti

ng

new

mea

sure

s

*id

enti

fy lo

cal i

nte

rest

s

(in

clu

din

g p

atie

nts

,

com

mu

nit

ies)

th

at n

eed

to

be

invo

lved

in im

ple

men

tin

g

EDS

*sh

are

asse

mb

led

info

rmat

ion

wit

h lo

cal

inte

rest

s so

th

ey p

arti

cip

ate

in a

nal

yzin

g p

erfo

rman

ce

and

set

tin

g o

bje

ctiv

es

*agr

ee r

ole

s w

ith

loca

l

auth

ori

ty (

e.g.

ser

vice

s th

at

shar

e th

e sa

me

clie

nte

le)

*id

enti

fy s

ervi

ce u

sers

at

risk

fo

r ex

clu

sio

n f

rom

par

tici

pat

ory

pro

cess

es,

pro

mo

te t

hei

r p

arti

cip

atio

n

*id

enti

fy a

nd

ove

rco

me

bar

rier

s to

par

tici

pat

ion

*mo

nit

or

and

eva

luat

e

par

tici

pat

ory

pro

cess

es

*use

fee

db

ack

to im

pro

ve

serv

ices

an

d s

har

e re

sult

s o

f

par

tici

pat

ion

wit

h p

ub

lic

DO

MA

INS

&

dim

en

sio

ns

CLA

S JC

R

CR

F C

OER

ED

S EQ

S

PR

OM

OTI

NG

RES

PO

NSI

VEN

ESS

Sharing information on experiences

*mak

e in

form

atio

n a

vaila

ble

to p

ub

lic o

n p

rogr

ess

and

inn

ova

tio

ns

in im

ple

men

tin

g

CLA

S

*in

form

co

mm

un

ity,

ow

n

org

aniz

atio

n (

for

inst

itu

tio

nal

izin

g C

LAS)

an

d

oth

er o

rgan

izat

ion

s to

lear

n

fro

m e

ach

oth

er

*sh

are

info

rmat

ion

wit

h

surr

ou

nd

ing

com

mu

nit

y

abo

ut

effo

rts

to m

eet

un

iqu

e p

atie

nts

’ nee

ds

to

dem

on

stra

te c

om

mit

men

t

*un

der

take

res

earc

h t

o

dev

elo

p n

ew a

nd

imp

rove

d

init

iati

ves

and

res

ou

rces

fo

r

CR

*in

form

pu

blic

ad

equ

ate

ly

abo

ut

issu

es c

on

cern

ing

mig

ran

t h

ealt

h

*sh

are

asse

mb

led

evi

den

ce

on

eq

ual

ity

per

form

ance

wit

h lo

cal i

nte

rest

s (e

.g.

pat

ien

ts, c

om

mu

nit

ies)

, so

they

can

tak

e p

art

in

anal

ysin

g p

erfo

rman

ce a

nd

set

goal

s

*pu

blis

h a

cco

mp

lish

men

ts

(gra

des

) an

d e

qu

alit

y

ob

ject

ive

s so

th

ey

are

acce

ssib

le f

or

loca

l in

tere

sts

*be

a p

arti

cip

ant

in

net

wo

rks,

res

earc

h

init

iati

ves

wh

ich

pro

mo

te

equ

ity

*dis

sem

inat

e re

sult

s o

f

rese

arch

/pra

ctic

e re

late

d t

o

equ

ity

*bu

ild s

olid

re

lati

on

ship

s/

net

wo

rks

wit

h c

om

mu

nit

y-

bas

ed s

ervi

ce p

rovi

der

s

*en

sure

th

at e

qu

ity

is

refl

ecte

d in

all

par

tner

ship

and

ser

vice

co

ntr

acts

UN

IQU

E IS

SUES

*id

enti

fy a

nd

ad

dre

ss

mo

bili

ty n

eed

s (e

.g. c

ane,

guid

ing

do

gs)

*su

pp

ort

wo

rkfo

rce

to

rem

ain

hea

lth

y, f

ocu

s o

n

maj

or

hea

lth

an

d li

fest

yle

issu

es t

hat

aff

ect

ind

ivid

ual

and

wid

er p

op

ula

tio

n

Tab

le 7

.3 D

escr

ipti

on

of

cla

ssif

ied

do

ma

ins

an

d d

imen

sio

ns,

an

d c

ove

rag

e o

f d

om

ain

s/d

imen

sio

ns

by

the

six

ap

pro

ach

es

(sh

ad

ed c

ells

vis

ua

lize

tha

t th

is d

imen

sio

n is

no

t co

vere

d b

y th

e a

pp

roa

ch)

DO

MA

INS

& D

ime

nsi

on

s C

LAR

IFIC

ATI

ON

OF

THE

DO

MA

INS

AN

D D

IMEN

SIO

NS

CLA

S JC

R

CR

F C

OER

ED

S EQ

S

OR

GA

NIZ

ATI

ON

AL

CO

MM

ITM

ENT

The

ob

ligat

ion

s h

ealt

h c

are

org

aniz

atio

ns

imp

ose

on

th

emse

lves

ab

ou

t p

rovi

din

g d

iver

sity

re

spo

nsi

ve c

are.

Po

licy

and

lead

ers

hip

O

rgan

izat

ion

s’ e

xplic

it c

om

mit

men

t to

pro

vid

e d

iver

sity

res

po

nsi

ve c

are,

dem

on

stra

ted

in p

olic

ies

and

lead

ersh

ip a

nd

inte

grat

ed in

reg

ula

r p

olic

ies.

Mea

suri

ng

and

imp

rovi

ng

per

form

ance

M

easu

rin

g o

rgan

izat

ion

s’ p

erf

orm

ance

rel

ated

to

div

ersi

ty r

esp

on

sive

car

e an

d im

pro

vin

g p

erfo

rman

ce

bas

ed o

n t

he

fin

din

gs.

CO

LLEC

TIN

G D

ATA

C

olle

ctin

g d

ata

to p

rovi

de

evid

ence

on

eq

uit

y o

f ac

cess

an

d o

f q

ual

ity

of

care

fo

r d

iver

se p

op

ula

tio

ns.

Dat

a co

llect

ion

on

th

e p

op

ula

tio

n a

t la

rge

Dat

a co

llect

ion

on

dem

ogr

aph

ics,

ch

arac

teri

stic

s re

leva

nt

for

serv

ice

use

, an

d h

ealt

h o

f th

e p

op

ula

tio

n

livin

g in

th

e g

eogr

aph

ical

are

a se

rved

by

the

hea

lth

car

e o

rgan

izat

ion

.

Dat

a co

llect

ion

on

th

e p

ati

ent

po

pu

lati

on

D

ata

colle

ctio

n o

f th

e p

atie

nts

bei

ng

serv

ed b

y th

e h

ealt

h c

are

org

aniz

atio

n.

STA

FF/W

OR

KFO

RC

E Is

sues

rel

ated

to

th

e ca

re p

rovi

de

rs, t

he

man

agem

ent

and

su

pp

ort

wo

rke

rs, t

hat

wo

rk a

t a

hea

lth

car

e o

rgan

izat

ion

.

Staf

f co

mp

eten

cies

Im

pro

vin

g co

mp

eten

cies

of

staf

f w

ork

ing

at a

hea

lth

car

e o

rgan

izat

ion

to

pro

vid

e re

spo

nsi

ve c

are

(e.g

.

by

trai

nin

g an

d o

ther

su

pp

ort

).

Div

ersi

ty in

wo

rkfo

rce

C

reat

ing

a d

emo

grap

hic

ally

div

erse

wo

rkfo

rce

of

a h

ealt

h c

are

org

aniz

atio

n a

nd

en

sure

eq

ual

op

po

rtu

nit

ies

amo

ng

all.

ENSU

RIN

G A

CC

ESS

Peo

ple

th

at n

eed

hea

lth

care

can

acc

ess

hea

lth

car

e se

rvic

es in

a t

imel

y m

ann

er a

nd

wit

ho

ut

bar

rie

rs.

Enti

tlem

ent

to c

are

Im

ple

men

tati

on

of

legi

slat

ion

on

en

titl

emen

ts f

or

the

use

of

hea

lth

ser

vice

s fo

r sp

ecif

ic g

rou

ps

(e.g

.

un

do

cum

ente

d m

igra

nts

).

‘Un

der

stan

dab

le’ i

nfo

rmat

ion

P

rovi

din

g in

form

atio

n a

dap

ted

to

lan

guag

e an

d h

ealt

h li

tera

cy n

eed

s o

f d

iver

se p

atie

nt

po

pu

lati

on

s to

faci

litat

e ac

cess

.

Geo

grap

hic

al a

cces

sib

ility

R

edu

cin

g ge

ogr

aph

ical

bar

rie

rs t

o a

cces

s.

Oth

er a

spec

ts o

f ac

cess

ibili

ty

Issu

es o

n e

nsu

rin

g a

cces

sib

ility

no

t d

iscu

ssed

in t

he

dim

ensi

on

s a

bo

ve

CA

RE

PR

OV

ISIO

N

Pro

vid

ing

goo

d q

ual

ity

hea

lth

car

e in

th

e co

nte

xt o

f p

atie

nts

’ div

ersi

ty.

Car

e re

spo

nsi

ve t

o n

eed

s an

d w

ish

es

Pro

vid

ing

care

th

at is

res

po

nsi

ve t

o d

iver

se p

atie

nts

’ nee

ds

and

wis

hes

.

Pat

ien

t p

arti

cip

atio

n in

th

e ca

re p

roce

ss

Pat

ien

t p

arti

cip

atio

n o

r in

volv

emen

t in

th

e in

div

idu

al c

are

pro

cess

.

Ove

rco

min

g co

mm

un

icat

ion

bar

rier

s in

pat

ien

t-p

rovi

der

co

nta

ct

Rem

ovi

ng

com

mu

nic

atio

n b

arri

ers

in t

he

pat

ien

t-p

rovi

der

co

nta

ct.

‘Un

der

stan

dab

le’ p

atie

nt

info

rmat

ion

mat

eria

ls

Rem

ovi

ng

bar

rier

s in

un

der

stan

din

g p

atie

nt

info

rmat

ion

mat

eria

ls (

wit

h r

egar

d t

o la

ngu

age

and

hea

lth

liter

acy

leve

l).

Tru

st

Bu

ildin

g tr

ust

bet

wee

n s

ervi

ce u

sers

an

d s

ervi

ce p

rovi

de

rs w

ith

reg

ard

to

pat

ien

t d

iver

sity

.

Pat

ien

ts’ r

igh

ts

Info

rm p

atie

nts

of

the

ir r

igh

ts.

DO

MA

INS

& D

ime

nsi

on

s C

LAR

IFIC

ATI

ON

OF

THE

DO

MA

INS

AN

D D

IMEN

SIO

NS

CLA

S JC

R

CR

F C

OER

ED

S EQ

S

PA

TIEN

T A

ND

CO

MM

UN

ITY

PA

RTI

CIP

ATI

ON

AT

OR

GA

NIZ

ATI

ON

AL

LEV

EL

The

pro

cess

th

at e

nab

les

pat

ien

ts a

nd

/or

com

mu

nit

ies

to p

arti

cip

ate

in p

lan

nin

g, d

evel

op

ing

and

del

ive

rin

g h

eal

th s

ervi

ces

at o

rgan

izat

ion

al le

vel.

Invo

lvin

g p

atie

nts

an

d c

om

mu

nit

ies

in

the

dev

elo

pm

ent

of

serv

ices

Effo

rts

to in

clu

de

all p

atie

nts

an

d c

om

mu

nit

ies

(in

clu

din

g th

ose

of

risk

to

be

excl

ud

ed)

in p

arti

cip

atio

n

acti

viti

es f

or

dev

elo

pm

ent

of

serv

ices

.

PR

OM

OTI

NG

RES

PO

NSI

VEN

ESS

Furt

her

ing

resp

on

sive

hea

lth

car

e in

th

e so

cie

ty t

o w

hic

h a

hea

lth

car

e o

rgan

izat

ion

bel

on

gs.

Shar

ing

info

rmat

ion

on

exp

eri

ence

s D

isse

min

atin

g ex

per

ien

ces

wit

h p

rovi

din

g d

iver

sity

res

po

nsi

ve h

ealt

h c

are

to

sta

keh

old

ers/

soci

ety.

(sh

ad

ed c

ells

vis

ua

lize

tha

t th

is d

imen

sio

n is

no

t co

vere

d b

y th

e a

pp

roa

ch)

Chapter 7 141

References

1. Smedley BD, Stith AY, and Nelson AR. Unequal Treatment: confronting racial

and ethnic disparities in health care. Washington, DC: The National Academies

Press. 2003

2. Vaccarino V, Rathore SS, Wenger NK, Frederick PD, Abramson JL, Barron HV,

Manhapra A, Mallik S, Krumholz HM. Sex and racial differences in the

management of acute myocardial infarction, 1994 through 2002. N Engl J Med

2005;353(7):671-82

3. Aarts MJ, Koldewijn EL, Poortmans PM, Coebergh JW, Louwman M. The impact

of socioeconomic status on prostate cancer treatment and survival in the

southern Netherlands. Urology 2013;81(3):593-9

4. de Bruijne MC, van Rosse F, Uiters E, Droomers M, Suurmond J, Stronks K,

Essink-Bot ML. Ethnic Variations in Unplanned Readmissions and Excess Length

of Hospital Stay: a Nationwide Record-linked Cohort Study. Eur J Public Health

2013;23(6):964-71

5. Fransen MP, Essink-Bot ML, Vogel I, Mackenbach JP, Steegers EA, Wildschut HI.

Ethnic differences in informed decision-making about prenatal screening for

Down's syndrome. J Epidemiol Community Health 2010;64(3):262-8

6. Goode TW, Like RC. Advancing and sustaining cultural and linguistic competence

in the American health system: challenges, strategies, and lessons learned. In:

Ingleby D, Chiarenza A, Devillé W, Kotsioni I, editors. Inequalities in health care

for migrants and ethnic minorities. Antwerp: Garant Publishers. 2012;49-65

7. Office of Minority Health, US Dept. of Health and Human Services. National

Standards for Culturally and Linguistically Appropriate Services in Health and

Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice.

2013. Available:

https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprin

t.pdf. Accessed 11 September 2013

8. Chiarenza A. Developments in the Concept of 'Cultural Competence'. In: Ingleby

D, Chiarenza A, Devillé W, Kotsioni I, editors. Inequalities in Health Care for

Migrants and Ethnic Minorities. Antwerp: Garant Publishers. 2012;66-81

9. Betancourt JR. Cross-Cultural Medical Education: Conceptual Approaches and

Frameworks for Evaluation. Acad Med 2003;78(6):560-9

142 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

10. Seeleman C, Suurmond J, Stronks K. Cultural competence: a conceptual

framework for teaching and learning. Med Educ 2009;43(3):229-37

11. Office of Minority Health, US Dept. of Health and Human Services. National

Standards for Culturally And Linguistically Appropriate Services in Health Care:

Final Report. 2001. Available:

http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf. Accessed 11

September 2013

12. Bischoff A, Chiarenza A, Loutan L. "Migrant-Friendly Hospitals": a European

Initiative in an Age of Increasing Mobility. World Hosp Health Serv 2009;45(3):7-

9

13. Mosko MO, Gil-Martinez F, Schulz H. Cross-Cultural Opening in German

Outpatient Mental Healthcare Service: An Exploratory Study of Structural and

Procedural Aspects. Clin Psychol Psychother 2013;20(5):434-46

14. Domenig D. The concept of transcultural competence (Das konzept der

transkulturelle kompetenz). In: Domenig D, editors. Transkulturelle kompetenz:

lehrbuch für pflege-, gesundheits- und sozialberufe, 2., vollständig überarbeitete

und erweiterte auflage. Bern: Verlag Hans Huber. 2007;165-189

15. Renschler I, Cattacin S. Comprehensive "Difference Sensitivity" in Health

Systems. In: Björngren Cuadra C, Cattacin S, editors. Migration and Health:

Difference Sensitivity from an Organisational Perspective. Malmö: Holmbergs.

2007;37-42

16. The Joint Commission. Advancing Effective Communication, Cultural

Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.

2010. Available:

http://www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion

727.pdf. Accessed 11 September 2013

17. Department of Health, State of Victoria. Cultural responsiveness framework -

Guidelines for Victorian health services. 2009. Available:

http://www.health.vic.gov.au/__data/assets/pdf_file/0008/381068/cultural_res

ponsiveness.pdf. Accessed 11 September 2013

18. Council of Europe. Draft Explanatory Memorandum of the Draft

Recommendation CM/Rec(2011) of the Committee of Ministers to Member

States on Mobility, Migration and Access to Health Care. 2011. Available:

https://wcd.coe.int/ViewDoc.jsp?Ref=CM(2011)141&Language=lanEnglish&Ver

Chapter 7 143

=add&Site=COE&BackColorInternet=DBDCF2&BackColorIntranet=FDC864&Back

ColorLogged=FDC864. Accessed 11 September 2013

19. Council of Europe. Recommendation CM/Rec(2011)13 of the Committee of

Ministers to Member States on Mobility, Migration and Access to Health Care.

2011. Available: https://wcd.coe.int/ViewDoc.jsp?id=1872157. Accessed 11

September 2013

20. NHS. The Equality Delivery System for the NHS. 2012. Available:

http://www.eastmidlands.nhs.uk/about-us/inclusion/eds/. Accessed 11

September 2013

21. Task Force on Migrant-Friendly and Culturally Competent Health Care.

Standards for Equity in Health Care for Migrants and Other Vulnerable Groups.

2013. Available:

http://wwwold.ausl.re.it/HPH/FrontEnd/Home/Default.aspx?channel_id=38.

Accessed 11 September 2013

22. Whitehead M. The concepts and principles of equity and health. Report nr.

EUR/ICP/RPD 414. Copenhagen: World Health Organization, Regional Office for

Europe. 1990

23. Suurmond J, Seeleman C. Shared decision-making in an intercultural context.

Barriers in the interaction between physicians and immigrant patients. Patient

Educ Couns 2006;60(2):253-9

24. Joint Commission International. Joint Commission International Accreditation

Standards for Hospitals. 4th Edition. 2011

25. Task Force on Migrant-Friendly and Culturally Competent Health Care. Project

to develop standards for equity in health care for migrants and other vulnerable

groups. Preliminary standards for pilot testing in health care organizations (Draft

2012). Available:

http://wwwold.ausl.re.it/HPH/FrontEnd/Home/Default.aspx?channel_id=38.

Accessed 11 September 2013

26. IOM (Institute of Medicine). Crossing the Quality Chasm: A new health system

for the 21st century. Washington, D.C: National Academy Press; 2001

27. Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and

healthcare quality. J Natl Med Assoc 2008;100(11):1275-85

144 Cultural competence and diversity responsiveness: how to make a difference in healthcare?

28. Vertovec S. Super-diversity and its implications. Ethnic and Racial Studies

2007;30(6):1024-54

29. Kirby JB, Taliaferro G, Zuvekas SH. Explaining racial and ethnic disparities in

health care. Med Care 2006;44(5 Suppl):I64-72

30. Martinez M, Cohen R. Health Insurance Coverage: Early release of estimates

from the national health interview survey, January - September 2012. 2013.

Available: http://www.cdc.gov/nchs/data/nhis/earlyrelease/Insur201303.pdf.

Accessed 11 September 2013

31. Ingleby D. Introduction by series editor. In: Ingleby D, Chiarenza A, Devillé W,

Kotsioni I, editors. Inequalities in health care for migrants and ethnic minorities.

Antwerp: Garant Publishers. 2012;9-25

32. Council of Europe. Statute of the Council of Europe. European Treaty Series 1.

1949. Available: http://conventions.coe.int/Treaty/en/Treaties/Word/001.doc.

Accessed 11 September 2013

33. Home Office. Public sector Equality Duty. 2012. Available:

https://www.gov.uk/equality-act-2010-guidance. Accessed 11 september 2013

34. Cross T, Bazron B, Dennis K, Isaacs M. Towards A Culturally Competent System

of Care, Volume I. Washington, DC: Georgetown University Child Development

Center, CASSP Technical Assistance Center. 1989