National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care

National Standards for

Culturally and Linguistically Appropriate Services (CLAS) in Health Care

Standards are issued by the U.S. Department of Health and Human Services (HHS)

Office of Minority Health

An Introduction to

Culturally and Linguistically Appropriate Services (CLAS) Standards

The New Mexico Department of Health, Office of Policy and

Accountability, Office of Health Equity is pleased to provide you with the following free online Culturally and Linguistically

Appropriate Services (CLAS) Standards course.

Source: U.S. Department of Health and Human Services, Office of Minority Health (April 2013) National Standards for CLAS in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice

This CLAS Standards course is designed to help prepare health care professionals, public health providers, community-based

providers, and all direct medical and social service providers to:

Understand why the CLAS Standards were developed.

Know how the CLAS Standards are organized.

Identify implementation strategies to comply with the CLAS Standards.

Increase confidence in implementing the standards in your health care office or facility to meet Federal mandates.

Although significant health care advances have been made over the past century:

• Ethnic, racial and other minority populations have not benefited from these improvements.

• As shown by their dramatically shorter life spans, higher morbidity rates and continued lack of access to quality care.

The United States continues to become a more culturally diverse society. Increased diversity has led to an increased demand for health care delivery that is responsive to multicultural populations.

The concept of health disparities is particularly important for New Mexico, a minority-majority state where greater than 50% of the population identifies as a racial or ethnic minority. Did you know? While the overall teen pregnancy rate in New Mexico

has continued to decline, there are still large disparities among Hispanics and American Indians.

Diabetes prevalence is lower in the border region than in the non-border region, but the opposite is true for diabetes mortality.

American Indians in New Mexico experience the highest rates of influenza- and pneumonia deaths, more than double the New Mexico and U.S. averages.

Blacks and African Americans continue to have higher percentages of low birth weight infants than any other race or ethnicity in New Mexico.

Asians or Pacific Islanders experience a disproportionate burden of chronic hepatitis B.

New Mexico

According to U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates

New Mexico’s total population: 2,080,085

Number Percent American Indian/Alaska Native 177,555 8.5 Asian/Pacific Islander 27,933 1.3 Black/African American 37,519 1.8 Hispanic 978,189 47.0 White 824,291 39.6 Two or more races 30,880 1.5 36.2% of New Mexicans over the age of 5 speak a language other than English

Why Were the Culturally and Linguistically Appropriate Service (CLAS) Standards Developed?

In 1994, the U.S. Congress required the Department of Health and

Human Services (HHS) to create standards for addressing the cultural and linguistic barriers to health care delivery and increase access to health care to people with limited English proficiency.

In 2000, HHS’ Office of Minority Health published the first National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care.

In 2013, the CLAS standards were enhanced to recognize increasing diversity and ensure relevancy to new national policies and legislation.

Purpose of CLAS standards

The purpose of the enhanced National CLAS Standards is to provide a blueprint for health and health care organizations to implement culturally and linguistically appropriate services that will advance health equity, improve quality, and help eliminate health care disparities.

Practical and ethical reasons to provide culturally and linguistically appropriate services:

1. To respond to current and projected demographic changes in the

United States. 2. To eliminate long-standing disparities in the health status of

people of diverse racial, ethnic and cultural backgrounds. 3. To improve the quality of services and primary care outcomes. 4. To meet legislative, regulatory and accreditation mandates. 5. To gain a competitive edge in the market place. 6. To decrease the likelihood of liability/malpractice claims.

What are the CLAS Standards?

The CLAS Standards are issued by the U.S. Department of Health &

Human Services’ Office of Minority Health.

CLAS standards ensure that all people entering the health care system receive equitable and effective treatment in a culturally and linguistically appropriate manner.

There are 15 CLAS Standards. All 15 Standards are necessary to advance health equity, improve quality, and help eliminate health care disparities.

As important as each individual Standard is, the exclusion of any Standard diminishes health professionals’ and organizations’ ability to meet an individual’s health and health care needs in a culturally and linguistically appropriate manner.

Thus, it is strongly recommended that each of the 15 Standards be implemented by health and health care organizations.

The CLAS Standards are organized into one Principle Standard and three themes:

1. Governance, Leadership, and Workforce

2. Communication and Language Assistance

3. Engagement, Continuous Quality Improvement and

Accountability.

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care

Principal Standard

1. Provide effective, equitable, understandable, respectful, and quality care and

services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

The Principal Standard is the essential goal of all of the Standards, and if the other 14 Standards are adopted, implemented, and maintained, then the Principal Standard will be achieved.


Theme One: Governance, Leadership and Workforce

2. Advance and sustain organizational governance and leadership that

promotes CLAS and health equity through policy, practices, and allocated resources.

3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.

4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.


Theme Two: Communication and Language Assistance 5. Offer language assistance to individuals who have limited English

proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.

6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.

7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.

8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Although the enhanced National CLAS Standards do not represent statutory requirements, failure by a recipient of Federal financial assistance to provide services consistent with Standards 5 through 8 could result in a violation of Title VI of the Civil Rights Act of 1964 implementing regulation (See 42 USC 2000d et. Seq. and 45 CFR Part 80).


Theme Three: Engagement, Continuous Improvement, and Accountability

9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.

10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities.

11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.

12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.


Theme Three: Engagement, Continuous Improvement, and Accountability (continued)

13. Partner with the community to design, implement, and evaluate policies,

practices, and services to ensure cultural and linguistic appropriateness.

14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.

15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

CLAS Standard #1

Purpose of Standard: To create a safe and welcoming environment at every point of contact that both

fosters appreciation of the diversity of individuals and provides patient and family-centered care

To ensure that all individuals receiving health care and services experience culturally and linguistically appropriate encounters

To meet communication needs so that individuals understand the health care and services they are receiving, can participate effectively in their own care, and make informed decisions

To eliminate discrimination and disparities

The Principle Standard: Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

CLAS Standard #2

Strategies for Implementation:* Create and sustain an environment of cultural competency through

establishing leadership structures and systems or embedding them into existing structures and systems.

Identify and develop informed and committed champions of cultural competency throughout the organization in order to focus efforts around providing culturally competent care.

Ensure that the necessary fiscal and human resources, tools, skills, and knowledge to support and improve culturally competent policies and practices in the organization are available.

*from the National Quality Forum, 2009

Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.

CLAS Standard #3

Strategies for Implementation:* Create a work environment that respects and accommodates the cultural

diversity of the local workforce. Develop, maintain, and promote continuing education and career

development opportunities so all staff members may progress within the organization.

Cultivate relationships with organizations and institutions that offer health and human service career training to establish volunteer, work-study, and internship programs

Joint Commission’s Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (2010)

Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.

CLAS Standard #4

Strategies for Implementation: Provide ongoing in-service training on ways to meet the unique needs of

the population, including regular in-services on how and when to access language services for individuals with limited English proficiency (Wilson-Stronks & Galvez, 2007).

Allocate resources to train current staff in cultural competency or as medical interpreters if they speak a second language, have completed language assessments, and show an interest in interpretation (QSource, 2005).

Provide opportunities for CLAS training that include regular in-services, brown-bag lunch series, orientation materials for new staff, and annual update meetings (QSource, 2005).

Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

CLAS Standard #5

Strategies for Implementation: Ensure that staff is fully aware of, and trained in, the use of language

assistance services, policies, and procedures (see Standard 4) (HHS OMH, 2005). Develop processes for identifying the language(s) an individual speaks

(e.g., language identification flash cards or “I speak” cards) and for adding this information to that person’s health record (QSource, 2005).

Use qualified and trained interpreters to facilitate communication (Wilson-Stronks & Galvez, 2007), including ensuring the quality of the language skills of self-reported bilingual staff who use their non-English language skills during patient encounters (Regenstein, Andres, & Wynia, in press).

Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.

CLAS Standard #6

Strategies for Implementation: Organizations should reflect the languages regularly encountered in the service area in their signs, materials, and multimedia resources (Berger, 2005; HHS OCR, 2003). For those who may not be literate, information can be conveyed orally or through signage using symbols or pictures (HHS OMH, 2005; Kashiwagi, 2004).

In deciding where to provide notice to individuals about the availability of language services, organizations should consider the following: Points of entry or intake, including: registration desks, front desks,

waiting rooms, financial screening rooms (where individuals may need to discuss and resolve billing issues), pharmacy reception, where individuals may pick up prescriptions (HHS OMH, 2005; Kashiwagi, 2004;)

Areas where clinical work is performed, such as triage and medical exam rooms (HHS OMH, 2005).

Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.

CLAS Standard #7

Strategies for Implementation: Depending upon an organization’s size, scope, and mission, its language assistance strategies will differ. Organizations may opt to provide interpretation services through in-person interpreters and bilingual staff and providers or through technological or electronic means, including telephonic or video remote interpreting. Translation may be conducted primarily internally or may be contracted to external organizations.

Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.

Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Strategies for Implementation: • Create forms that are easy to fill out, and offer assistance in completing forms

(AHRQ, 2010). • Formalize processes for translating materials into languages other than English

and for evaluating the quality of these translations (Wilson-Stronks & Galvez, 2007).

• Develop materials in alternative formats for individuals with communication needs, including those with sensory, developmental, and/or cognitive impairments (The Joint Commission, 2010).

• Test materials with target audiences. For example, focus group discussions with members of the target population can identify content in the material that might be embarrassing or offensive, suggest cultural practices that provide more appropriate examples, and assess whether graphics reflect the diversity of the target community. (HHS OMH, 2001).

Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.

Strategies for Implementation: Engage the support of governance and leadership, and encourage the

allocation of resources to support the development, implementation, and maintenance of culturally and linguistically appropriate services.

Encourage governance and leadership to establish education and training requirements relating to culturally and linguistically appropriate services for all individuals in the organization, including themselves.

Establish accountability mechanisms throughout the organization, including staff evaluations, individuals’ satisfaction measures, and quality improvement measures (QSource, 2005).

CLAS Standard #9

Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities.

CLAS Standard #10

Strategies for Implementation: Conduct an organizational assessment or a cultural audit using existing

cultural and linguistic competency assessment tools to inventory structural policies, procedures, and practices. These tools can provide guidance to determine whether the core structures and processes (e.g., management, governance, delivery systems, and customer relation functions) necessary for providing CLAS are in place.

Use results from assessments to identify assets (e.g., bilingual staff members who could be used as interpreters, existing relationships with community-based ethnic organizations), weaknesses (e.g., no translated signage or cultural competency training), and opportunities to improve the organization’s structural framework and capacity to address cultural and linguistic competence in care (e.g., revise mission statement, recruit people from diverse cultures into policy and management positions).

Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.

CLAS Standard #11

Strategies for Implementation:*

Ask for data early-ideally during admission or registration Properly trained admissions or reception staff could collect data Before obtaining information, develop a script to communicate that:

This information is important. It will be used to improve care and services and to prevent discrimination. This information will be kept confidential. Allow for an opportunity to address any concerns up front and clearly.

Have individual self-report (select their own race, ethnicity, language, gender identity, etc.)

Use standard collection instruments. Store data in standard electronic format. Massachusetts Department of Public Health, Office of Health Equity, 2009

Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.

CLAS Standard #12

Strategies for Implementation:

Partner with other organizations to negotiate a data sharing agreement, which could facilitate the linking of different types of data.

Collaborate with other organizations and stakeholders in data collection, analysis, and reporting efforts to increase data reliability and validity.

Review demographic data collected with local health and health care organizations (QSource, 2005).

Use multiple sources in the community to collect data, including faith-based organizations, social workers, and managed care organizations (QSource, 2005).

Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.

CLAS Standard #13

Strategies for Implementation: Partner with local culturally diverse media to promote better understanding of

available care and services and of appropriate routes for accessing services among all community members (Wilson-Stronks & Galvez, 2007).

Build coalitions with community partners to increase reach and impact in identifying and creating solutions.

Collaborate to reach more people, to share information and learn, and to improve services. Work with partners to advertise job openings, identify interpreting resources, and organize health promotion activities. Successful partnerships benefit all.

Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.

CLAS Standard #14

Strategies for Implementation:

Provide cross-cultural communication training, including how to work with an interpreter, and conflict resolution training to staff who handle conflicts, complaints, and feedback.

Provide notice in signage, translated materials, and other media about the right of each individual to provide feedback, including the right to file a complaint or grievance.

Develop a clear process to address instances of conflict and grievance that includes follow-up and ensures that the individual is contacted with a resolution and next steps (QSource, 2005).

Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

CLAS Standard #15

Strategies for Implementation: Provide information which may include (HHS OMH, 2001): Demographic data about the populations Utilization and availability statistics related to interpreters and translated

materials Level of staff training in cultural and linguistic competency CLAS-related expenditures and cost-benefit data Assessment results based on activities suggested from Standard 10,

community data collected in accordance with Standard 12, and the number of complaints and their resolution as collected pursuant to Standard 14

• People involved in health care delivery interact with individuals from many different cultural and linguistic backgrounds.

• Culture and language are vital factors in how health care services are delivered and received.

• Health care providers must understand and respond with sensitivity to the needs and preferences that individuals bring to the health encounter.

• Providing culturally and linguistically appropriate services improves access to care, quality of care and health outcomes.

Why are CLAS Standards Important?

Why are the CLAS Standards Important?

Culture and language may influence:

• Health, healing and wellness belief systems.

• How illness, disease and their causes are perceived.

• The behaviors of individuals who seek health care and their attitudes toward health care providers.

• The delivery of services by providers, who carry their own set of values that can affect access and treatment.

New Mexico Department of Health (NMDOH), initiated a program in 2006 in which bilingual employees received Spanish and Navajo Medical Interpreter training. More employees are expected to complete this program in 2016. Employees who successfully complete the Medical Interpreter training are qualified to serve as language interpreters for clinics, public health offices, hospital providers and limited-English speaking patients.

Efforts of New Mexico Department of Health to meet Cultural and Linguistic mandates

Efforts of New Mexico Department of Health to meet Cultural and Linguistic mandates

In 2015, the New Mexico Department of Health re-established the Health Equity Workgroup. Members represent a variety of DOH programs throughout the state. Projects of Health Equity Work Group include: Updating CLAS training Creating Toolkit with a variety of language access and cultural resources Create a Public Health Spanish Curriculum Conduct annual CLAS assessment Assist in annual Health Equity Report

For more information about these projects please see the links on the homepage or contact: Rosalie Nava, Training and Outreach Coordinator, Office of Health Equity at 505-827-2572 or [email protected]

For more information on the sources cited in this presentation, additional implementation suggestions, and/or more detailed

explanation of the standards please visit the U.S. Department of Health and Human Services, Office of Minority Health and

download: A Blueprint for Advancing and Sustaining CLAS Policy and Practice, April 2013

http://minorityhealth.hhs.gov/

Culturally and Linguistically

Appropriate Services (CLAS) Standards Quiz

For a certificate of completion, please complete the CLAS quiz. You will be able to take the quiz as many times as needed to correctly answer 80% or better. Once you start, you must complete the quiz. If you choose to exit the quiz before completion, the test will reset and you will start from the beginning.

TAKE THE TEST http://nmdohcc.org/login/index.php

Documents

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care