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Review of Current Cultural and Linguistic Diversity and Cultural Competence Reporting Requirements, Minimum Standards and Benchmarks

for Victoria Health Services Project Literature Review


Published by the Statewide Quality Branch Victorian Government Department of Health Melbourne Victoria August 2009 © Copyright State of Victoria, Department of Health, 2009 The publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968. Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne. This document can be downloaded from the Department of Human Services web site Acknowledgements This report was written by the Institute for Community, Ethnicity and Policy Alternatives, Victoria University Edited by: Patrice Higgins Funded by: The Department of Human Services The text represents the views of the authors and may not represent the views of the State Government.


........................2 International standards.............................3 Selected Commonwealth and State Policies and Reporting Frameworks................10 4........................37 8.71 Minimum Reporting Requirements Under HSCDP...................................................................................................74 Culturally and Linguistically Appropriate Services and Standards (USA)...............73 Appendix 3.21 7.................................................................................... Mapping Cultural Diversity Policy.........9 3............1 Australian Standards...................32 7. MODELS OF CULTURAL COMPETENCE.................................................... CONCLUSION.30 Health Service Cultural Diversity Plan (HSCDP) ...........................................1 Discussion and Analysis: How do the models guide intervention?....................... DEFINING CULTURE...49 9.............................................. CULTURAL COMPETENCE AND CULTURAL DIVERSITY............................................................................ STANDARDS OF CULTURAL COMPETENCE FOR HEALTH SERVICES .............76 4 .................................................................................................8 2...............................................................................71 Appendix 2....30 7..................CONTENTS EXECUTIVE SUMMARY................44 8...............................................................................................................................73 Core Strategies of the Cultural diversity plan for Victoria’s specialist mental health services 2006–2010........................................................ Planning and Reporting Arrangements for Cultural Diversity ....................................................................... GOVERNMENT POLICY AND REPORTING FRAMEWORKS FOR CULTURAL DIVERSITY ...............58 11...............43 8................63 RESOURCES..................... RELEVANCE OF CULTURAL COMPETENCE TO HEALTH AND WELLBEING.3 Discussion...................................................2 Discussion.........48 8.............................................61 REFERENCES.......34 7. INTRODUCTION ....................................................................................... CULTURE AS A FACTOR IN SAFETY AND RISK MANAGEMENT IN HEALTH SYSTEMS..........................................................6 1...........1........12 5........71 Appendix 1.............. LITERATURE REVIEW METHODS ....................................................18 6.................. INDICATORS AND ASSESSMENT TOOLS................................................................. TOWARDS A FRAMEWORK OF CULTURAL COMPETENCE ASSESSMENT..................................74 Appendix 4..52 10..........................................................14 5.........................................................................................................................

......................................78 Mental Health Assessment Tools............Lewin Group Cultural Competence Domains (2002).....................87 5 ..................................................76 Appendix 5...........................................78 Cultural Competence Assessment Tools.........................................................

A systematic approach was adopted to identify. both Australian and international. critically evaluate and synthesise relevant information from international. A review on standards of cultural competence found a lack of national standards in relation to the provision of culturally and linguistically appropriate health services. reports. academic databases. The National Quality Framework suggested that a standardised core set of performance measures based on cross-cultural quality issues that is broadly applicable across all healthcare settings should be adopted. The review was commissioned by the Statewide Quality Branch of the Victorian Department of Human Services (the department). Cultural competence in healthcare has emerged partially as a strategy to address racial and ethnic disparities that may lead to health inequalities. have documented the benefits of a culturally competent health care system to potentially reduce health disparities among populations from culturally and linguistically diverse (CALD) backgrounds. refereed journal articles. Some studies suggested that in order to minimise risks. especially in terms of preventable adverse events in patients of minority backgrounds. conference papers. it was determined that there is no conclusive and agreed upon definition of these concepts. discussion papers and websites which are commonly referred to as grey literature. Victoria University. there is little conclusive evidence on cultural competence framework/s and their efficacy in reducing health inequalities. keynote speeches. minimum standards and benchmarks for health services. However. In the review of policy and reporting frameworks for cultural diversity it was noted that there are many complex reporting and planning arrangements within the Department of Human Services. diversity. Its main aim was to conduct a review of cultural and linguistic diversity and cultural competence reporting requirements. 6 . and Examination and identification of key interventions and their enablers for cultural diversity and cultural competence together with evidence of the efficacy of these interventions within health services. Mapping and analysis of current national and international literature on cultural diversity and cultural competence focusing on reporting requirements. The review included documents available from on-line sources. government policy statements and government and non-profit organisation publications. health care organisations needed to integrate cultural competence into their internal quality improvement activities. cultural diversity and cultural competence arose throughout the literature. Through analysis of these definitions. Various definitions of culture.EXECUTIVE SUMMARY This literature review was prepared by the Institute for Community. Commonwealth and state documents. minimum standards and benchmarks for health services incorporating: • • • Mapping and analysis of current department cultural diversity and cultural competence reporting requirements for Victorian health services from department and health service perspectives. Several studies document that failure to consider a patient’s cultural and linguistic issues can present risk/s to health services and their clients. Ethnicity and Policy Alternative (ICEPA). Several studies.

The recommendations from this project were launched as the ‘Amsterdam Declaration towards Migrant Friendly Hospitals in an ethno-culturally diverse Europe’. A core recommendation from this declaration is the need to define what cultural competence means. Research indicates there are benefits of integrating cultural competence into health care delivery systems. and at a service level to: • • ‘find consensus on criteria for migrant-friendliness. The review concludes that there is much written on cultural diversity and cultural competence in healthcare. Effective outcomes of integrating cultural competence into health services can be achieved by developing and implementing a customised holistic approach and embedding it into the organisational context with an ongoing monitoring and review system. From the existing models and strategies reviewed in the literature. and to integrate them into professional standards and to enforce their realisation in everyday practice’. cultural competence and diversity competence that are adapted to their specific situation. some key headings are provided to assist in developing a range of agency specific measures and indicators. and in supporting other hospitals through compiling practical knowledge and instruments. culturally competent health care and health promotion higher on the European health policy agenda.A number of cultural competence assessment frameworks were reviewed in the context of health care services and it was found that models of cultural competence needs to be embedded within organisational processes. 7 . An example from the Migrant-friendly Hospitals Project highlights the initiative of the European Union in putting migrant-friendly.

develop a practical strategic framework for the development of appropriate standards for cultural diversity and cultural competence interventions for Victorian health services and make recommendations as to a minimum set of standards. Mapping and analysis of current national and international literature on cultural diversity and cultural competence focusing on reporting requirements. and the establishment of cultural competence reporting methodology. minimum standards and benchmarks for health services. 2. Ethnicity and Policy Alternatives (ICEPA) to develop and implement a project plan incorporating a review of Cultural and Linguistic Diversity (CALD) and cultural competence reporting requirements. minimum standards and benchmarks for health services. content. together with evidence of the efficacy of these interventions within health services. Using the results of Objectives 1-3. Examination and identification of key interventions and their enablers for cultural diversity and cultural competence. Test the strategic framework and recommended minimum set of standards with health services and members of Cultural Diversity Committees (CDCs) at one statewide workshop and report on project findings to the Statewide Quality Branch. 4. 3. Minimum Standards and Benchmarks for Victoria Health Services Project. The second purpose of this literature review is to generate a framework to inform decisions about the scope. 5. Mapping and analysis of current department cultural diversity and cultural competence reporting requirements for Victorian health services. and mechanisms to enhance any existing frameworks for culturally competent health care services.1. The key objectives of the project are: 1. The review has two overlapping and interrelated purposes: • The first is to synthesize and examine the current understanding of cultural and linguistic diversity and cultural competence. This literature review component of the project report incorporates the first three objectives and forms the first step in the Review of Current Cultural and Linguistic Diversity and Cultural Competence Reporting Requirements. • 8 . documentation of organisational frameworks that support cultural competence. measurement of cultural competence amongst health care personnel. from department and health service perspectives. INTRODUCTION The Department of Human Services (the department) has commissioned Victoria University’s Institute for Community.

Documents commonly referred to as grey literature available from on-line sources. Limitations: The searches were conducted for publications dating back to 1990. Victoria. critically evaluate and synthesise relevant information. reporting. The review notes that while there is a plethora of articles on ‘cultural competence’ there is less material on reporting and monitoring of cultural competence. A further search was carried out using academic databases for example Medline. South Australia). No other limitations were set. provided models of cultural competence in health care and explored issues in implementation of cultural competence in health settings such as planning. Information Sources: A wide range of information sources were searched including: • • • • • • • • • • • • • Medline Cumulative Index to Nursing and Allied Health Literature (CINAH) The Agency for Healthcare Research and Quality website Multicultural Australia and Immigration Studies (MAIS) Cochrane Library Proquest Sage Journals on-line Google Scholar Georgetown University. Articles covered were in English only. Commonwealth and state documents was conducted using various combinations of key words and phrases for example cultural diversity and cultural competence. government policy statements as well as government and non-profit organisation publications. measurement of cultural responsiveness. safety and culture in health care. LITERATURE REVIEW METHODS Approach: This literature review adopts a systematic approach to identify. discussion papers and websites are also included. CINAHL. racism and safety and risk in health care settings and benchmarks for health services. excluding materials that were in other languages. reporting requirements and minimum standards. standards. Inclusion and Exclusion Criteria: Articles were included if they defined cultural competence and cultural diversity in health settings.2. As there are a large number of articles on cultural competence. conference papers. and a range of ‘on line’ full text journals.National Centre for Cultural Competence website European Commission Migrant Friendly Hospitals Project website American Government Websites Commonwealth Government Websites State Government Websites (NSW. reports. those that did not relate to health settings were generally excluded. Search Strategy: A search of international. indicators and challenges/enabling factors. Queensland. key note speeches. The types of references used include refereed journal articles. and scant literature on benchmarks and indicators. 9 .

however it tends to focus on the rights of individuals and groups. attitudes and policies that come together in a system. The National Quality Forum notes (2002) that there is an absence of standardised frameworks. The declaration promotes cultural diversity to the level of common heritage of humanity. Accordingly. religion. Normative. cultural diversity and cultural competence were generated from relevant literature. logic and definition of cultural competence. cultural competence is a set of congruent behaviours. DEFINING CULTURE. it can be more than an awareness of cultural differences. UNESCO’s Universal Declaration on Cultural Diversity. Diversity as a concept is broad and tends to refer to groups or individuals that are perceived to be different from the general community (Centre for Culture Ethnicity and Health. Kroeber and Kluckhohn claimed to have identified 160 different definitions representing different groups. custom. the major challenge is how to define.’ In 1952. Although the notion of cultural competence is not conclusive there is some acceptance in the academic community about its definition as suggested by Cross et al (1989). CULTURAL COMPETENCE AND CULTURAL DIVERSITY Various definitions of culture. diversity. for example. arts. 2006 pp. Given the scope and complexity of the concept. implying it as ‘a source of exchange. resists any exhaustive or conclusive definition (Effa-Ababio. culturally and linguistically diverse communities are those whose members identify as having nonmainstream cultural or linguistic affiliations by virtue of their place of birth. Culture is a much written about concept.3. 1989). While the case for the benefits of cultural competence from a clinical and business standpoint is accepted. values and beliefs (Fitzgerald. as it can be used to improve health and well being by integrating culture into the delivery of health services (National Health and Medical Research Council. assess and measure 10 . The term cultural and linguistic diversity refers to the range of different cultures and language groups represented in the population. In popular usage. As well. 2005). Efforts to define cultural competence and its application within the health care context are continuing. preferred language or language spoken at home. Aboriginal organisations prefer that the needs of Australian Aborigines be considered separately. innovation and creativity…as necessary for mankind as biodiversity is for nature’ (UNESCO. as early 1871 Edward Tylor defined it as: ‘…that complex whole which includes knowledge. 2003). However before defining cultural diversity and cultural competence. morals. 2002). culture. Behavioural. Cultural competence can be viewed at an individual level whereby it is the ability to identify and challenge one’s cultural assumptions. ancestry or ethnic origin. rather than under the framework of cultural and linguistic diversity (Department of Human Services. agency or among professionals and enable that system. and Symbolic. 2005). Structural. Mental. Cultural diversity is also another broad concept. adopted unanimously in 2001. belief. 43). law. Functional. agency or those professionals to work effectively in cross-cultural situations (Cross et al. it is vital to understand the concept of culture. 2000). is the most articulated understanding of cultural diversity. Topical. and any other capabilities and habits acquired by man as a member of society.

The definition of cultural competency ‘culture’ is often reified and not treated as a dynamic and changing factor increasing the risk of perpetuating cultural stereotypes (Greg and Saha. Definitions have focused on the individual or clinician level. Various definitions of cultural competence exist however. organisational or structural aspects of cultural competence. 2006). Although there is no consensus on a single defining there is some agreement that building cultural competence capacity will improve health care delivery to diverse populations. Brach and Fraser 2000). the definition by Cross et al (as noted above) seems to be most widely quoted.cultural competence (Betancourt et al 2002. 11 . Some definitions recognise both the individual. and the organisational level.

In our culturally and linguistically diverse society. which include not only country of birth and levels of English but also the process of migration. born in Australia. The health status of migrants can vary according to a range of factors. In reality the health and wellbeing of culturally and linguistically diverse communities depends on a complex balance of social. professional and individual (NHMRC 2006. RELEVANCE OF CULTURAL COMPETENCE TO HEALTH AND WELLBEING Australia is a multicultural country with approximately one in four people being born overseas. organisational. or enhance their response to the disease should it occur (AIHW. Net overseas migration has consistently accounted for more than half of Victoria’s population increase. For many migrants and refugees the impact of settlement and acculturation varies widely depending on their experience and circumstances. had either one or both parents born overseas. Risk factors are characteristics. variables. 2002). While immigrants and refugees often enter Australia with better physical health due to screening processes (NSW Health. The promotion of healthier living for culturally diverse communities is linked to both ‘risk’ and ‘protective’ behaviours that are related to immigration. ethnicity. The Institute of Medicine (2008) concludes that one major contributor to health inequalities is a lack of culturally competent care and that by providing culturally 12 . Protective factors reduce the likelihood of a person suffering a disease. The National Health and Medical Research Council (NHMRC) points out that: All Australians have the right to access health care that meets their needs. stage in the life course. if present for a given individual. rather than someone selected at random from the general population.4. Health and wellbeing are governed by many factors. ‘race’ and culture. 2005). this right can only be upheld if cultural issues are core business at every level of the health system-systemic.1). employment. This diversity is growing faster than at any other time in Victoria’s history and the trend is expected to continue. will develop a disorder ( Multicultural Mental Health Australia. such as housing. and mental health (AIHW.8 per cent of the population were born overseas and an additional 19.7 per cent of Victorians. Victoria is among the fastest-growing states in Australia and according to the 2006 ABS Census. economic. pp. had a resident population of almost five million people. and environmental factors. make it more likely that this individual. community capital and support and each individual’s balance of protective and risk factors. 2004). cancer. education. community networks and supports and access to essential services. This effect has been documented for physical health outcomes such as cardiovascular disease. some outside the health system. 2004) they may have worse levels of mental health that are associated with the stressors of migration (Reid and Tromph. or hazards that. In Victoria 23. 1990) and any health advantage shown by immigrants usually disappears over time.

and result in improved access and quality of care for culturally diverse populations. ‘Culture’ is central in the delivery of health care services. increase efficiency of clinical and support staff and improve satisfaction among patients. or the studies did not examine the outcome measures their review was evaluating. Brach and Fraser (2000) are able to demonstrate that health systems and clinicians’ ability to deliver appropriate services to diverse populations can be improved. Fielding. attitudes towards medical care. most appropriate care and services. and found health systems have limited evidence to suggest otherwise.appropriate services there is potential to reduce disparities and improve outcomes. Cultural competence has been promoted as a way for health services and organisations to respond effectively to the cultural and linguistic needs that patients bring to the health care encounter (US Department of Health and Human Services. including meeting patients’ social. as well as policies and structures that enable them to work effectively in cross-cultural situations. they conclude that cultural competence should work. Green and Carrillo (2002) conclude cultural competence in healthcare systems shows the ability of systems to provide care to patients with diverse values. since it can influence patients’ health beliefs. understood. and levels of trust. ethnicity. medical practices. Cultural differences can impact on how health information is provided. enables self-determination and ensures a commitment to reciprocity for culturally and linguistically diverse consumers and their communities. and holds governments. Anderson. but they could not determine the effectiveness of any of these interventions because there were either too few comparative studies. NHRMC (2006:4) notes that a health system that is culturally competent: • • • • acknowledges the benefits that diversity brings to Australian society. cultural and linguistic needs. beliefs. 2005). Scrimshaw. and behaviours. health organisations and managers accountable for meeting the needs of all members of the communities they serve. Cultural competence then requires organisations to have a clearly defined and matching set of values and principles. and Normand (2003) reviewed five interventions to improve cultural competence in health care systems. Clinical barriers in health care delivery could be overcome by addressing cultural differences. helps health Services and consumers to achieve the best. Betancourt. Cultural competence in healthcare has emerged partially as a strategy to address racial and ethnic disparities that may lead to health inequalities. 2001). It focuses on the capacity of the health system to improve health and wellbeing by integrating culture into the delivery of health services (NHMRC. In the Australian context. Fullilove. 13 . and acted upon. They state that the goal of cultural competence is to create a health care system and workforce that are capable of delivering the highest-quality care to every patient regardless of race. cultural background and English proficiency.

This statement begs the question. Finally. respect for differences. and seeking information on how diseases and health conditions affect particular groups. systems not being intentionally destructive. MODELS OF CULTURAL COMPETENCE In the closing plenary of a convention on ‘Building Culturally Competent Health Systems in California’ Joseph Betancourt. Massachusetts. systems being perceived as fair for all to the knowledge that systems have flaws in dealing with minority issues. ‘what needs to be done to create a health care system that has the ability to respond to any patient’s need?’ This section will explore potential answers to that question through key models of cultural competence and their outcomes in the context of both Australian and overseas health care systems. Director of the Disparities Solutions Centre. In an influential model. General Hospital stated. developed by Cross et al (1989) cultural competence is envisaged as a continuum through: • • • • • • Cultural Cultural Cultural Cultural Cultural Cultural destructiveness incapacity blindness pre-competence competence proficiency. A number of models of cultural competence have been developed. cultural desire is the motivation of an individual to engage in each of the stages of being coming culturally competent as described above. Cultural skill is the ability to collect relevant data on the client’s presenting problem and to know their overall health status.5. ‘…ultimately what we want is a health care system that can respond to the need of any patient’. The progression from cultural destructiveness whereby the attitudes. and finally to cultural proficiency holding 14 . Cultural knowledge is gaining an understanding of the world-views of different cultural and ethnic groups. A key model is that developed by Campinha-Bacote (1999. policies and practices are destructive. 2002) who argues that cultural competence has five interdependent elements: • • • • • Cultural Cultural Cultural Cultural Cultural Awareness Knowledge Skills Encounters Desire. Cultural awareness involves a process of self-examination of one’s own cultural and professional background and biases towards others and being aware of one’s own prejudices that may affect health care delivery. Cultural encounters are the process of engaging with individuals from other cultures with the view to modifying existing assumptions about a cultural group and prevent stereotyping. which encompass the different dimensions that cultural competence should address.

language and communication barriers. need to allocate appropriate resources to ensure cultural competence is embedded into organisations. and health outcomes. attitudes and behaviours defining culturally competent behaviour are maximised and made more effective by existing within a supportive health organisation and wider health system. Professional — over-arching the other dimensions. In another study that focussed on reducing ethnic children’s health disparities. Muriel Bamlett (2007) has applied this as a useful concept to understanding cultural competence in Aboriginal Children’s Services and has illustrated how this model can be used to analyse approaches by mainstream agencies to Aboriginal culture and history such as the Stolen Generations. It also results in specific professions developing cultural competence standards to guide the working lives of individuals. treatment plans.cultural differences and diversity in high esteem. at this level cultural competence is identified as an important component in education and professional development. clinical-patient perceptions and realities. organisational and professional training and assessment procedures. Management is committed to a process of diversity management including cultural and linguistic diversity at all staffing levels. Andrulis (2005) suggests the need to: • collect and use race/ethnicity data for the review of program. Policies support the active involvement of culturally diverse communities in matters concerning their health and environment. differential access to care. Organisational — the skills and resources required by client diversity are in place. Individual — knowledge. appropriate and sustainable health promotion programs. embracing this model. for example to conduct policy. This model represents an interesting view that perceives organisations moving through two extremes on the continuum through time. These are: • • • • • biological and genetic influences. The National Health and Medical Research Council (2006:29) model acknowledges four dimensions of cultural competence: Systemic — effective policies and procedures. A culture is created where cultural competence is valued as integral to core business and consequently supported and evaluated. service. 15 . and Health Service effectiveness. Individual health professionals feel supported to work with diverse communities to develop relevant. Health care systems. quality of care disparities. mechanisms for monitoring and sufficient resources are fundamental to fostering culturally competent behaviour and practice at other levels. Andrulis (2003) identified five dimensions that address the major causes of disparities that can exert significant influence over the success and quality of the patient-physician relationship.

It is a holistic framework that incorporates nine categories of cultural competence in health settings: • • • • Interpreter services. understanding the role and legacy of racism and discrimination on health and familial relationships. public information campaigns. Including family and/or community members. leading to changes in staff (both clinical and administrative) behaviour and patient-staff interactions. as they would with any other care provider. staff who reflect the demographics of the patient population. A variety of administrative and organisational decisions related to clinic locations. Administrative and organisational accommodations. pp. or customs of the family in medical decisions. This can take several forms: health professionals’ screening tools. healing practices. In addition. Andrulis talks of the need ‘for research to extend through and beyond the clinical encounter to address the role of the health care setting and system’ (Andrulis 2005. brief interventions. with each health care setting recognising its importance to the process. and other culturally influenced priorities must be integrated into health care interactions. Coordinating with traditional healers. Understanding the role. network membership. and understanding the cultural context for health care decision-making is critical for effective clinical encounters. (their advocacy and empowerment function is important). aimed at increasing cultural awareness. recognising the significant influence of culture on health. as well as integrating cultural competence into quality of care. Training in cultural competence. oral and written materials must accommodate a diverse range of health literacy needs and reflect an understanding of life course experience. Immersion enables participants (health professionals) to overcome their ethnocentrism. Recruitment and retention of minority staff or. and can serve as guides to the health system. norms.• • bridge the communication divide to reduce language and communication barriers. While patient autonomy has become a core principle of Western health care. presenting patient education in a conceptual framework that harmonises with traditional healing practices may increase the chances that patients will concur with treatment recommendations. Immersion into another culture. knowledge and skills. rituals. Use of community health workers as they are known and respected by the community. 377). The health promotion messages can be made more culturally competent and specific. some minority groups involve family members in health care decision-making. For example. In doing so. health professionals needing to coordinate with these healers. more generally speaking. as the most common way to improve communication among persons who speak different languages. and develop knowledge and skills that integrate factors affecting children from diverse backgrounds. hours of operation. The framework proposed by Brach and Fraser (2000) is developed based on knowledge gained from fieldwork undertaken across sectors and so captures realistic issues and offers practical suggestions. Culturally competent health promotion. physical environments and written materials can also affect access to and use of health care • • • • • 16 .

Clinical cultural competence: The role of cross-cultural education and training including education in cultural competence for senior management. managed care. Gerrish and Emami (2006) identified nine most frequently cited models of cultural competence and undertook a content analysis that revealed four themes: 17 .These categories attempt to provide rigor from various points of health provision that can work at multiple levels such as organisational. The framework includes the following components: • Organisational cultural competence: This involves reflection of racial and ethnic diversity in health care leadership and work force. Patient empowerment is also a source of cultural competence. academia. including racial and ethnic disparities (Brach and Fraser. health care requires an understanding of the communities being served including the impact of socioeconomic influences on individual patients’ health beliefs and behaviors. and in education and training. and mechanisms for addressing racism and bias. and interface between traditional healers and health professionals. poor comprehensive and compliance. Systemic cultural competence: Systemic barriers such as a lack of interpreter services. developing contractual requirements (federal and state). 2000). and community health care delivery. The authors provide a framework for the implementation of culturally competent practices based on these suggestions. Inclusion of community members in health care process and formally including community health advocates and recruiting staff from diverse communities would enhance cultural competence in the organisation. Then. and lower quality care. Jirwe. Accordingly. recruitment. culturally and linguistically appropriate health education materials can lead to patient dissatisfaction. community. for hospitals and medical schools). Betancourt et al (2002) identified benefits of cultural competence to the health care systems by interviewing health care experts in government. communication skills. The conceptual framework does not address the need for additional resources to make many of these activities possible. and formulating accreditation standards (for example. and staff is vital in the provision of quality care. The authors also note that there is insufficient research evidence to suggest the effect of particular cultural competence techniques on any outcomes. • • Strategies for attaining cultural competence included: • • • using health care purchasers (government and private). Based on their exploratory exercise they came up with some key suggestions for developing the cultural competence framework. there is a need to devise strategies to reduce and monitor potential barriers through interventions. health services. The focus of training should be on socioeconomic factors. and how these factors interact with the health care system in ways that may prevent diverse populations from obtaining health care.

3. pp. A number of models of organisational change for cultural competence have been put forward which develops cultural competence in agencies. Romeo (2007. Similarly.1. 2. 5. and 4. 2. 206) states that cultural competence is a ‘learning process that enables individuals and organisations to function effectively in the midst of cultural difference’. He points to the need to view cultural competence as an ongoing process of organisational transformation in a continuum from early to later stages of development. Tirado (1998) proposes a five-stage model of organisational change: 1. 3. 4. this is based on the premise that to know the other culture one needs to know one’s own. 3. 2. 18 . This means. 5.1 Discussion and Analysis: How do the models guide intervention? All these models have both strengths and weaknesses. that for health care organisations to become more culturally competent they will need to engage in a change process of organisational transformation. An awareness of diversity among human beings to provide a culturally competent care. The models point to elements of change: • • Identifying where and how change can occur along a continuum. This entails engaging in a change process from a monoculture to a pluralistic environment. and Suggesting that the cultural continuum is not an end point but an ongoing process. 4. Dreachslin (1996) proposes a five-stage change model from affirmative action to valuing diversity encompassing a number of dimensions: 1. An ability to care for individuals requires the need to communicate effectively with the clients to know the client needs and their belief systems and to develop a mutually acceptable health management plan. Enhancing cultural competence as a long-term continuous process that requires learning. in order to provide culturally sensitive care. 5. or an environment that accepts and integrates people from diverse cultural backgrounds. Discovery Assessment Exploration Transformation Revitalisation. reflection and improvement on the part of Health Services. Culturally Culturally Culturally Culturally Culturally resistant unaware conscious insightful versatile. A non-judgemental openness—an aspiration on the part of the health service to overcome their own prejudices.

and advocacy taking into consideration cultural care. a culture of improving. Berson and Iscel (2006) advocate a case for a culturally inclusive holistic approach to implementing cultural competence through various initiatives. This approach has been used at the Ethnic Disability Advocacy Centre. evidence of improved outcomes and a commitment to striving for best practice. in Western Australia. 19 . projects and strategies in order to reach different target groups in the community. From the above example. This inclusive system of service delivery strives for substantive equality with both health service and the consumers. In some ways this approach is similar to a quality assurance system whereby quality of a system is improved through monitoring and feedback. The approach includes provision of services such as: employment. Fernandez and Lemon. In an effort to address cultural diversity in Australian health services. It illustrates provision of services in a culturally competent manner. cultural values. and would assist health services to avoid stereotyping by encouraging staff to ask their patients questions. Cultural competence models tend not to consider the structural causes of health care inequalities (Gregg. a study was undertaken by Allotey. responsibilities and practices. At the same time vital feedback from the consumers and carers is received and utilised to further improve services. There are a number of assessment tools that have been developed (see below) as instruments to measure change. They suggest the following characteristics to be associated with organisations that continually improve their performance: a patient/client group focus. transport. home care. However as cultural competence is gaining popularity in health care and social policy there is a need for a clearly defined and agreed upon definition. and that the notion of culture tends to be oversimplified in the notion of cultural competence (Gregg and Saha. it can be assumed that in order to ensure that the needs of individuals and groups from Non-English speaking and CALD backgrounds are met the issue of equity needs to be treated in the same manner as the issue of quality. 2005). health. education. values. industry and the community. It requires a respect for the ‘expertise’ of the patient and incorporates the active involvement of each patient and their family/carers. cultural responsibilities and cultural practices. framework. The Centre for Cultural Ethnicity and Health (2003) conclude that quality improvement can provide a broad framework for responding to the needs of individuals and groups from non-English speaking backgrounds. as consideration is given to cultural care. 2006). and has resulted in many positive outcomes for individuals. strong leadership. recreation. Manderson and Reidpath (2002) that used applied anthropological approaches to negotiate style and content for a set of resource materials designed to be used by health Services in community health and hospital settings. As noted earlier in the paper there is no conclusive definition of cultural competence.The usefulness of the models lies in unpacking the different dimensions of what they suggest might constitute cultural competence and in determining strategies for action. This approach is based on the philosophy that rather than using a pre-existing checklist on cultural imperatives to obtain cultural knowledge a health care professional would ask their patient ‘who is the cultural expert’ not them. and criteria to implement and assess its efficacy. independent living. Bussey-Jones. The resulting guide shows best practice for clinical care regardless of cultural or linguistic diversity.

The model requires a balanced workforce inclusive of Aboriginals and Torres Strait Islander people. Anderson et al (2003) reviewed five interventions to improve the cultural competence of health care systems. We were unable to find any further studies evaluating the success or impact of these interventions. programs to recruit and retain staff reflecting cultural diversity of the community served 2. The models described in this section provide some guidance for interventions. management being sensitive to cultural needs and risk management that reflects cultural differences. The authors state they could not determine the effectiveness of these interventions because there were either too few comparative studies. skilled practice and behaviour. the literature on this field is scant. The major drawback of this review is that the interventions were carried out over time and in different settings. It proposed the need for equity of outcomes for both individuals and communities achieved through quality assurance mechanisms. strong relationships and equity of outcomes. This model was grounded on the premise that an understanding of cultural heritage coupled with formal education and training would instigate a change in attitudes and behaviour that then needs to be endorsed through a strong management process. and inappropriate racial or ethnic differences in use of health services or in received and recommended treatment. and specific examples have been provided.Australian Health Minister’s Advisory Council (2004) advocated an Indigenous framework that included knowledge and awareness. culturally specific health care settings. or the studies did not examine the outcome measures evaluated in the review. These outcomes were: client satisfaction with care. cultural competence training for healthcare worker 4. The interventions included: 1. use of interpreter services for clients with limited English proficiency 3. While we are aware that there is good practice. improvement in health status. 20 . use of linguistically and culturally appropriate health education material 5. Perhaps the results would have been different if the interventions were undertaken in conjunction with other changes at organisational level such as commitment at senior management level with a defined plan and allocation of resources.

treatment and preventative services that the average population receive (Johnstone and Kanitsaki. Safety and Managing Risk Several studies show that minority and migrant patients are not receiving the same level of health care in terms of diagnosis. According to Stewart (2006) culturally competent health care is a good business practice. and helps to: • • • • • improve access and equity for all groups of population. improve consumer health literacy and reduced delays in seeking health care and treatment. 2007. improve patient safety and quality assurance. Kelly and Bancroft.6. With regard to the Australian context. 2007. Johnstone and Kanitsaki (2006) contend that those responsible for the design and delivery of health care can do more to improve the status quo in regard to ensuring the responsiveness of the Australian health care system to the health and care needs of resident minority racial and ethnic groups. 2008. improve communication and understanding of meanings between health consumers and Health Services. 2007. and improve public image of a health service. 2007. King et al. 2007. Overall. 2006. 2007). The following section will discuss key issues and challenges of integrating cultural competence into health care. Johnstone and Kanitsaki. 2007) and are less likely to receive the same level of care for numerous health issues including: less aggressive treatment of colorectal cancer. we can conclude that the health disparities may be a result of inadequate interaction between health and culture and/or due to the inability of healthcare systems to address the health care needs of individuals from CALD background. From these studies. Paradies (2006) found that the relationship between discrimination and poor mental health is well established. 2000) more misdiagnosis of mental illness with less adequate treatment (Fiscella. There are other related ways to consider ‘culture’ in health systems. 2002). More recently. Smith and Betancourt et al. they receive fewer orthopaedic procedures (Ronsaville and Hakim. Like. Kreps. Most of the practice frameworks in Australia have engaged with cultural diversity in heath care from an inclusion and multiculturalism perspective. a better use of resources. Serizawa. 21 . CULTURE AS A FACTOR IN SAFETY AND RISK MANAGEMENT IN HEALTH SYSTEMS The benefits of integrating cultural competence into health care have been well established. this literature suggests that that in Australia and internationally the health status of racial and ethnic minority groups tends to be poorer than that of the average population of the countries in which they reside (Anderson et al 2003. and that much more needs to be done.

Implementing policies to ensure equity and access to health services and promotion for a diverse population. and Develop and maintain a culturally competent health workforce. preventing patients from exposure to unnecessary risks. literacy and beliefs. Similar issues are confirmed by Flores (2000) in that failure to consider a patient’s cultural and linguistic issues can result in: • • • • • • • • • • • Inaccurate histories Decreased satisfaction with care Non-adherence Poor continuity of care Less preventive screening Miscommunication Difficulties with informed consent Inadequate analgesia A lower likelihood of having a primary care provider Decreased access to care Use of harmful remedies. According to Bischoff (2003) a number of factors are likely to be relevant in culture as a factor in safety and risk management. Address research gaps about the contribution of systemic risk factors (such as access to health services) to inequalities in health for CALD background communities. delayed immunisations 22 . Plan and delivering culturally competent and appropriate health promotion and health services. length of stay. The Institute of Medicine (2002) in USA argues that patient safety is not solely about addressing general systems issues to prevent the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (such as administering the wrong medication or dosage). and ensuring informed consent. NHMRC (2005:16) point out that for the health sector in Australia will need to: • • • • • • Address similarities and differences within communities based on gender. These can include a trajectory of errors and risks in health systems relating to: • • • • • • • • • • • Diagnostic testing Medication Pain management Medical follow-up Admission Referral Food and diets Patient adherence Patient information/understanding Patient reporting/complaints Patient participation. age.These issues offer insights into what health services in Australia should be doing. It also entails: avoiding misdiagnosis. Address systemic attitudes to cultural diversity that can influence how communities survive and succeed.

These issues clearly suggest risk to both health services and their clients. the national independent bodies which determines accreditation standards for health services. 23 . They highlight the need for a more strategic and systematic approach to health service delivery to culturally and linguistically diverse groups and the need to set as a national priority the ‘alignment of cultural safety and cultural competence initiatives with national and local organisational clinical risk management programs and related patient safety and quality care initiatives.’ Proposed Strategic Framework and Standards  Developing and implementing a national strategic framework for improving culturally and linguistically appropriate services in healthcare in Australian states and territories. However. guidelines. The stated mission of the Australian Council on Healthcare Standards (ACHS).181) highlight the need to develop and implement a national agenda for research on cultural safety and cultural competence in healthcare under the auspices of NHMRC/ARC.achs.• Fewer prescriptions. This they believed could be achieved by ensuring that patients from minority racial and ethnic backgrounds got safe care and did not suffer mishaps and harm because of ineffective communication or because of lack of cultural awareness on the part of staff. The standards developed should have their focus mandates. Johnstone and Kanitsaki (2007 pp.  Developing and operationalising national standards for culturally and linguistically appropriate services in healthcare in Australian states and Central to this. A lack of risk management of cultural differences can lead to major issues for both health services and recipients. A recent study conducted by Johnstone and Kanitsaki (2007) found that most participants interviewed had not previously heard of the term ‘cultural safety’ before receiving information from the researchers. it was also noted that participants had a sense that cultural safety was a complex process primarily concerned with health services ‘doing things safely’. and recommendations pertaining to: o Culturally safe and culturally competent care (including culturally competent and safe organisations) o Language access services o Organisational supports for cultural safety and cultural competence (including mandates for funding bodies to ensure the provision of appropriate human resources and funding). On a more positive note however. is to ‘improve the quality and safety of health care’ this includes cultural safety (http://www. These authors cite many examples of litigation. there is no doubt that every aspect of care delivered to culturally and linguistically diverse clients has the potential to be less than optimal if language and cultural barriers are not addressed as a matter of According to Johnstone and Kanitsaki (2006) issues of culture and language and the risks associated with cultural misunderstandings and failure to use professional health interpreters have long had legal implications in terms of preventable adverse events in patients of minority backgrounds.

2000. with the aim to reduce racial. Performance measures that relate cultural competence as part of overall performance management will assist in ‘culture’ being included in quality assessments. with many at double risk: at risk of receiving less optimal care because they are part of a minority community and the additional risk posed by language barriers (Stewart et al. Lack of explanation about medication correlated with later non-adherence and patient dissatisfaction (Manderson and Allotey. Bischoff. and identifies areas where cultural competence could be embedded: • Identify patients who need care: Since both the CCM and DM create registries of patients with specific chronic conditions (for example. However. The quality of physician/patient communication affects outcomes. 2002). poorer health outcomes (Brach and Fraserirector. Johnstone and Kanitsaki. language and safety and quality of care and that if this issue is not addressed patients from culturally and linguistically diverse backgrounds are exposed to preventable risks. Betancourt (2006a) reviews specific quality improvement approaches. In addition. diabetes). 2007. 2003. poor compliance to medications and health promotion strategies. patient satisfaction and patient health outcomes (Bischoff. Markove and Broom. Flores. Including these measures in performance management systems elevates their importance for the institution . 2000. such as disease management (DM) and the chronic care model (CCM). Organisations need to integrate cultural competence into their internal quality improvement activities. a culturally 24 . this can be fundamental to an organisation-wide approach to planning and implementation of continuous improvement in performance. 2003). Kelly and Bancroft. These authors argue that patient safety programs tend to underestimate or understate the critical relationship that exists between culture.Quality of Care and Culture It is noted by Omeri (2004:26) that governments hold health services accountable for delivering services that are appropriate for consumers from culturally and linguistically diverse backgrounds. There is substantial evidence that language barriers and miscommunication have adverse affects on the quality of care received. researchers are slow to demonstrate that link. According to Bischoff (2003) less satisfactory aspects of care in language discordant consultations lead to issues with quality such as: • • • • meeting patients’ needs giving explanations showing respect during the consultation process giving follow-up information. 2007. (2006:383) point out that. 2000) was also noted. This raises the question of cultural competence as an issue of quality and quality assurance. it was found that patients were more likely to miss follow-up appointments and skip medication and more likely to use hospital emergency rooms and have longer median in-patient days in hospital (Levin-Zamir. Johnstone and Kanitsaki. Research tells us that there is a conclusive link between cultural and language considerations in clinical contexts. 2007). ethnic and social disparities in health care and health outcomes. 2007). The standard of patient-provider communication is a strong indicator of the quality of health care provided.

physicians could be enlisted to help. Beach et al (2006) point out that there is congruence between cultural competence and patient-centred care. 2006: 298. They state: ‘…to deliver individualised care. 2007. physicians could be provided with information solicited by other health care team members regarding patients' understanding of their conditions or their fears and concerns about a medication. Provide care by tailoring the methods used to the patient's needs: In CCM and DM programs. and language proficiency would enable health teams to identify issues as they arise. physicians. 2005. Johnstone and Kanitsaki. needs and values and that these values guide all clinical decisions (Beach and Saha et al. When health services fail to understand socio-cultural differences between themselves and their patients. e-mail. communication and trust between them may suffer leading to a perceived or actual diminishment in the quality of care expressed by patients (Johnstone and Kanitsaki. case management nurses. such as their physical environment and ability to exercise. a provider must take into account the diversity of patients' perspectives. Provide physicians. alternative health beliefs. and other needs. It aims to elevate quality for all patients. and language proficiency and thus geared to identify racial/ethnic disparities in health care. through telephone contact. but each emphasizes different aspects of quality. 2006).• • • • competent approach would ensure that these registries are stratified by race. and physician organisations with feedback on their performance: Stratifying performance feedback by race. Support patients in their ability to help manage their own illnesses: To make this process culturally competent. Jeon and Burke. Thus. Smith and Betancourt. Westwood. Evidence exists that health services who are at the forefront of caring for people from CALD backgrounds do not have an acceptable level of knowledge and understanding of the nature and implications of cultural competence in health care (Chenoweth. for example. Patient Centred Care and Culture Patient centred care is defined as care that is respectful and responsive to individual patient preferences. Support physicians and multidisciplinary teams in their clinical decision-making: Once sociocultural barriers to care are identified and interventions to address them are put in place. teams. For example. Campesino. and address them as they emerge in distinct populations. Both patient-centeredness and cultural competence aim to improve health care quality. 2006). A culturally competent approach would establish ways to communicate with patients with limited English proficiency. culture. physicians' clinical decision-making and care management strategies could be informed by information about patients' sociocultural barriers to care and can engage in culturally competent approaches to address them. In addition. Cioffi. and group visits. selfmanagement advice and strategies should take into account key issues related to patients' social context. The primary goal of the patient-centeredness movement has been to provide individualised care and restore an emphasis on personal relationships. ethnicity. and so—to the extent that patient-centred care is delivered 25 . 2006. and other members of multidisciplinary care teams seek to communicate with patients outside of the traditional office visit. limited health literacy. ethnicity. 2008). 2007. educational information could be provided to patients in the appropriate languages and reading levels.

2002. subconscious bias. and those who receive it. and behaviours of individuals. health services must firstly be made aware of the impact of social and cultural factors on health beliefs and behaviours. Johnstone and Kanitsaki. Smith (2002) and the Department of Human Services (2008) suggest that migrant and minority health care issues need to be framed as quality issues. It is noted in the Lewin Report (2002) that the multifaceted and interconnected nature of cultural competence domains tend to overlap and do not occur in mutually exclusive categories. and the active participation of community members and consumers. Congruent with this view Johnstone and Kanitsaki (2007) note. that cultural safety should be viewed both from the perspective of the consumer and the Health Service. Central to this is the development of a sense of partnership in care. A culturally competent system of care reflects and responds to the communities it serves through its administrative policies and procedures. and that self-care is supported as well as treatment. The implication for CALD clients is that their cultural needs. understand the impact of stereotyping (Taylor and Lurie. be equipped with the tools and skills to manage these factors appropriately through training and education and they should empower patients to be active partners (Betancourt and Carrillo. and facilitation of patient involvement in decision making about treatment decisions. Likewise. hiring practices. also report better health outcomes (Little et al. This will impact negatively on communication about diagnosis and treatment. Congruent with this view the Australian Resource Centre for Healthcare Innovations (ARCHI: 1) provide this definition of a culturally competent health care system: ‘…staff within a culturally competent health care system honour and respect beliefs. 26 . 2001). Self-assessment. training and professional development. care should also become more patientcentred’ (2006). According to Smith and Betancourt et al (2007) in order to address racial and ethnic health disparities from the consumer provider perspective it is necessary to examine and understand attitudes. and the active incorporation of findings from these assessments into practice are essential elements of culturally competent systems. as there is evidence that institutional discrimination has an influence both on health outcomes and on community attitudes (VicHealth.’ Patient-centred care can be described generally as an approach that emphasises attention to patients’ psychosocial as well as physical needs. 2007). In order to attain higher levels of quality of care for CALD clients within hospital systems.universally—care should become more equitable. if a service is not culturally sensitive. and that interventions need to focus on the quality of overall care at both individual and organisational levels. and stereotyping. 2004). families and communities they serve. then partnership with patients in care will be ignored. histories and social contexts that impact on health will be taken into account. to the extent cultural competence enhances the ability of health care systems and providers to address individual patients' preferences and goals. This approach also emphasises that treatment choice takes patient preferences into account. interpersonal styles. that health service staff and patients may bring to the clinical encounter. among. Patients have been found to prefer patient-centred care. Cultural competence is a life-long process which includes the examination of one’s own attitudes and values. attitudes. such as mistrust. and the acquisition of knowledge and appreciation of cultural differences and similarities within. and between groups. Therefore changing the attitudes and behaviour is necessary in order to achieve results in the medium and long term. culturally based needs assessments. 2007).

and Fearn. in the person’s home was also pronounced. Bremner. monitor and report on participation to the community and the Department of Human Services. The Victorian Government Department of Human Services has commissioned the National Ageing Research Institute to support and evaluate best practice in personcentred health care in Victorian Health Services (Dow. The Department has identified the following key priority actions: • • • • Promote the rights and responsibilities of patients to the community. or on whether these interventions might be applicable to Health Services other than physicians. Key issues in person-centered care involve effective participatory approaches. representatives or nominees into the quality and safety program. and Evaluate. having good management support and working within an organisation that values its staff was identified as important. Community representatives or nominees to be involved in the review of system level issues regarding consumer and carer feedback and complaints. Entwistle. representatives or nominees in all aspects of the organisation’s planning and development. staff development. Various organisational support issues were also identified that require attention to achieve both positive culture and practice change. community members. Communicate and provide information about treatments and care to consumers and carers that is developed with consumers and. Ensure position descriptions include participation component . the inability to provide care in an environment considered most ideal for that person – that is. Skea. 2006). carers listen and act on the decisions their consumers make about their care and treatment. Haralambous. problems with staff 27 . However. Provide staff training and education on how to use the different types of participation. carers. The aim of this initiative is to make sure that older people are being cared for in the context for their individual situation. carers and community members about health care and treatment. where appropriate. It includes co-ordination of language services. Provide accessible information to consumers. Communicate clearly and respectfully with consumers and carers. and policy and procedure development and implementation.Lewin. The issue of capacity was even more pronounced for acute services than sub-acute. Integrate participation of consumers. For example. and to empower them and the people who care for them to be involved in decision-making. consumers and carers. and Zwarenstein (2001) undertook a study on patientcentred approach in clinical consultations and concluded that interventions to promote patient-centred care within clinical consultations may significantly increase the patient centredness of care. carers and community members. there is limited and mixed evidence on the effects of such interventions on patient health care behaviours or health status. • • • • • • The survey found the Health Services lacked the service capacity to providing the person centred care. Barriers included high staff turnover. The Program delivers a strategic and comprehensive response to assist staff in providing quality care to patients from CALD backgrounds. Include the involvement of consumers. including interpreting and translating.

gender. treatment. There is a need to develop particular kinds of policies and procedures in hospitals that support cultural competence. supports ‘top down’ the provision of person-centred care and seeks to both receive and act on consumer feedback was also considered necessary (Dow. Consumer Knowledge and Empowerment Health literacy is a new concept that focuses on the ability to use the health care system appropriately and to live a healthy lifestyle (Davis et al. there is a need for organisational commitment to cultural competence and subsequent action at the policy and procedures level. 1998). Beach et al (2006) argue that because cultural context is relevant to the needs of all patients. Finally. 2008). past experience with the health system.centered care can provide a mechanism to be inclusive of CALD patients in care delivery. values. finding common ground) may be endorsed as aspects of cultural competence. In addition. and patient and family knowledge. Haralambous. Cordero. person centered approaches can accommodate familycentered care. Brach and Fraser (2000) have also offered the notion of ‘family centeredness. she argues that the concepts form the basis for improving health indicators. While recognizing that certain privacy regulations and laws exist. as determined by the patient. and Galvez. It is also important that patients should be 28 . it is evident that patient. building rapport. cultural competence has the capacity to enhance patient-centeredness and improve quality for all patients. gender and culture. Kopp. not only to those of culturally diverse backgrounds. It is suggested by Levin-Zamir (2007) that it is important to understand the association between cultural competence.recruitment. and the meaning of illness. From the above. skills necessary to communicate with family members with attention to age. as these initiatives can often be overshadowed by other organisational priorities (Wilson-Stronks. the empowerment. At the core of both patient centeredness and cultural competence is the emphasis on seeing the patient as a unique person. First. Knowledge and understanding the role that family play in healthcare decisions become important considerations. staff feeling ‘pressured to discharge’ patients before they are ready and lack of good mentoring. beliefs and cultural backgrounds are incorporated into the planning and delivery of care. Bremner. Health literacy is dependent upon education. include family members in decision making when requested. The next argument made is that. empowerment and health literacy for three specific reasons. The general characteristics of patientcentered care (for example. In a study conducted by VicHealth (2007) it was found that the health consequences of discrimination can be moderated if people have a positive ethnic identity and a realistic appraisal of the existence and extent of discrimination affecting their group. hospitalizations due to mistakes and misunderstandings. 2006: 70). age. and Fearn. Working within an organisation that values and prioritises the care of the older person. respecting the potential wish of culturally diverse groups to include their family members in healthcare decision-making. values. honor patient and family perspectives and choices. cultural competence and health literacy connection has significance regarding the use of public resources for health care and that health costs increase due to costs that stem from the increased need for repeated examinations. This includes knowledge of culturally defined composition and roles within families. it is noted that the personal cost can be of personal shame and harm that is caused to self-esteem by an unpleasant encounter with a health service. exploring patient beliefs. Lee.

2007. Smith and Betancourt. subconscious bias and mistrust in relation to health services (Johnstone and Kanitsaki.aware of their own attitudes. 2007). 29 .

Multicultural Victoria Act 2004 and its proposed amendments. Valuing Cultural Diversity 2002. policies. Racial and Religious Tolerance Act 2001. and Charter of Human Rights and Responsibilities Act 2006. The broader policy context for cultural diversity is primarily informed by the principles contained in following Victorian legislation: • • • • Equal Opportunity Act 1995 (currently under review). The department operates within the larger policy and legislative framework of the Victorian Government (in addition to the Commonwealth).gov. legislations and planning and reporting arrangements. contains four themes: • Valuing diversity • Reducing inequality • Encouraging participation • Promoting the social. The purpose of this section links to Objective 1. This document identifies shared goals are a focus for setting government priorities and includes high-quality accessible health and community services and a fairer society that reduces disadvantage and respects diversity ( Mapping Cultural Diversity Policy. aged care and mental health. It is a complex agency with different areas of responsibility including health. GOVERNMENT POLICY AND REPORTING FRAMEWORKS FOR CULTURAL DIVERSITY This section will firstly map out the cultural diversity policy. This reporting is stipulated in the Multicultural Victoria Act 2004 where government departments are required to report annually to the Minister for Multicultural Affairs and parliament on their 30 . children.7. The department implements programs and services consistent with the Growing Victoria Together: A Vision for Victoria to 2010 which aims to achieve outcomes relating to economic.vic. housing. The department and other Victorian government agencies report on achievements against Victoria’s multicultural affairs policy each year as part of a whole-ofgovernment approach to multicultural affairs. The Victorian Government’s overarching multicultural affairs policy. frameworks. disability. cultural and economic benefits of cultural diversity to all Victorians. 7. social and environmental concerns. The large scale of the department and the multiple service delivery areas within entails numerous linkages. planning and reporting frameworks in the Victorian Department of Human Services.1. This will be followed by a selected exploration of what other state and Commonwealth governments are undertaking. as set out in the introduction of this literature review. Planning and Reporting Arrangements for Cultural Diversity The Department of Human Services is the largest Victorian government department.

In line with its multicultural affairs policy it notes that ‘Victoria’s cultural diversity provides a significant challenge for the Department and its funded agencies. 2. 6. 4. and are treated with respect and sensitivity’ (DHS. The six areas are: 1. families and communities Reducing inequalities through improving health and wellbeing. The department’s Cultural Diversity Guide points out that the delivery of culturally responsive. particularly for disadvantaged people and communities. Understanding clients and their needs Partnerships with multicultural and ethno-specific agencies A culturally diverse workforce Using language services to best effect Encouraging participation in decision making Promoting the benefits of a multicultural Victoria.achievements in the multicultural arena. The department has tried to address t cultural diversity by developing a comprehensive Cultural Diversity Plan 2007-2008 which maps out actions against particular objectives. This policy recognises effective communication to be essential to the delivery of highquality services. to access professional interpreting and translating services when making significant life decisions and where essential information is being communicated (http://www. and Cultural Diversity Plan for Victoria’s Specialist Mental Health Services. 3. the department’s Diversity Unit has developed a guide which establishes six strategy areas for improving cultural responsiveness under a Cultural Diversity Guide (2006).dhs. While cultural diversity principles are adopted by the department. or who speak limited English. The department of reports through the Diversity Unit against the four broad themes listed above. Disability Services Cultural and Linguistic Diversity Strategy. well-managed and efficient human services Providing timely and accessible human services Improving human service safety and quality Promoting least intrusive and earliest effective care Strengthening the capacity of individuals. 2006:6). equitable services is a core quality expectation of the department programs and funded agencies. In addition it has adopted a Language Services Policy (2005). 5. The objectives of the Departmental Plan 2008-09 are: • • • • • • Building sustainable. The departmental planning and reporting for cultural diversity form the foundations of the Cultural Diversity Plan 2007-2008 and incorporate the following: • • • • Health Service Cultural Diversity Plan (HSCDP). in ensuring that Victorians from all backgrounds can enjoy access to human services on an equal footing. It outlines the necessary requirements to enable people who cannot speak English.vic. Home and Community Care (HACC) Cultural Planning These will be visited briefly to provide an overview and to analyse the commonalities and differences across these reporting areas: 31 .

The 32 . develop and implements a health service cultural diversity plan. The current Victorian Standards for Disability Services 1999 (the ‘Standards’) represent the minimum operational standards for government and nongovernment disability support services in Victoria. The Disability Services Cultural and Linguistic Diversity Strategy was launched in 2004 and its objective is to meet the needs of people from culturally and linguistically diverse backgrounds with a disability. case management. advocacy. The minimum reporting set out in the cultural diversity guide applies to the HSCDP and includes reporting against areas including: • • • • • • data knowledge skills language engagement education. Please see Appendix 1 for details of the minimum reporting requirements. information. a number of strategies have been developed. their family and carers.Health Service Cultural Diversity Plan (HSCDP) The Health Service Cultural Diversity Plan’s objective is to improve the quality of service delivery and ensure that health services cater appropriately for culturally and linguistically diverse communities (Department of Human Services. including: • • • • Consumer assessment Service delivery self assessment Management self assessment Development and implementation of quality plans. The minimum reporting requirements identified in this plan are six areas under the Cultural Diversity Plan and health services (hospitals) report against these. 2008). lodge the plan with the Director. The purpose of the Strategy is to assist all disability support providers to plan and deliver culturally appropriate disability supports. The Intellectually Disabled Person’s Services Act 1986 (Vic) and The Disability Services Act 1991 (Vic). respite. Statewide Quality Branch and from 2007 onward every service is required to report annually on the plan’s accomplishments. These providers include government and non-government organisations that deliver supports such as accommodation. There are standards for service providers which are embedded strongly in planning and quality assurance processes. Disability Services Cultural and Linguistic Diversity Strategy Based on The State Disability Plan 2002-2012 of the Victorian Government this strategy is underpinned by a legislative framework which includes the Disability Discrimination Act 1992 (Commonwealth). day programs. Since 2006 every Victorian health service has had to establish a cultural diversity committee. To ensure that the standards are implemented by organisations. Equal Opportunity Act 1995 (Vic). support packages and recreation.

HACC Program National Complaints Policy and Statement of Rights and Responsibilities. The Tool conforms to the National Service Standards and seven principles around which planning takes place: Access. Cultural Relevance. As part of the Commonwealth State/Territory Disability Agreement. monitoring and implementing the CALD Strategy is through integration into existing practices. The mechanisms for planning. Consumer Survey Instrument and Guidelines. the department’s Disability Services Division coordinates the Victorian collection for the National Minimum Data Set.Strategy is located within a more regulated framework and has a stronger legislative and monitoring framework than HSCDP. These areas are then supported by broad indicators. Service Coordination and Accountability. The department funds 14 HACC Equity and Access Program (HEAP) projects based in community agencies. It is supported by a number of tools and resources such as Cultural Planning Tool guidelines and resources. The department is a partner to the Commonwealth and State/Territory Disability Agreement (CSTDA). The ‘HEAP workers’ resource the service providers and support them in the development of 33 . However. HACC Services also has to undertake data collection for the National Minimum Data Set. Special Needs Programs. The Victorian HACC program is supported by the HACC Program Manual which sets out legislative and policy frameworks and covers issues of implementation. The requirement of this data collection has changed from a single day snapshot approach to an ongoing full year collection. The seven goals in the Disability Services CALD Strategy are: • • • • • • • Understanding people and their needs Encouraging participation in decision-making Providing culturally relevant and accessible information A culturally diverse workforce Using language services to best effect Meeting the specific needs of different communities Promoting the benefits of a culturally diverse Victoria. These are based on the original six principles identified in the Cultural Diversity Plan. HACC service delivery occurs within the National Quality Assurance Framework which comprises the HACC National Service Standards. HACC Program National Service Standards Instrument and Guidelines. Home and Community Care (HACC) Cultural Planning Strategy (CPS) This strategy has been in place since 1997 and its overall objective is to increase the responsiveness of HACC services to people from culturally and linguistically diverse backgrounds who were identified as one of the five ‘special needs groups. Consultation. The Act recognises that people from culturally and linguistically diverse might experience difficulties in gaining access to HACC services. The Victorian HACC Cultural Planning Strategy is designed to be used by HACC service providers to demonstrate and evaluate the provision of culturally appropriate services to people from CALD backgrounds. As part of this agreement. within the broader HACC target population under the Commonwealth Home and Community Care Act 1985. there are similarities in the planning and reporting frameworks for cultural diversity. CPS requires HACC providers to develop and submit HACC Cultural Action Plan each year. Information.

it identified that the Strategy made a positive influence on participation of CALD communities at the local government level. responsiveness of services to cultural diversity including issues of language services. improving service responsiveness to cultural diversity. The Victorian Government is a signatory to the National Mental Health Strategy which is an agreement between the Commonwealth and State/territory governments. Commonwealth State Agreements and the presence of National Service Standards. The key strategies adopted in the plan are listed in Appendix 2. These are linked to a number of factors including: • • • historical developments of service provision or policy area within the department. appropriate workforce and recruitment and training. monitoring of funding agreements. but in operationalising the planning and reporting processes. The Cultural Diversity Guide (2006) provides the skeletal framework for planning and reporting. A number of commonalities exist in each of the different cultural diversity planning and reporting areas deriving from the Guide. Action on Disability within Ethnic Communities (ADEC) is funded to play a coordination role for HEAP workers across Victoria. access by culturally and linguistically diverse communities to services. strengthening quality. These documents emphasise the need for cultural sensitivity. ensuring Cultural Action Plans are submitted and overseeing implementation more broadly. cultural sensitivity. 7. and fostering culturally inclusive research and innovation. consumer participation. and overall promotion of multiculturalism or a commitment to cultural diversity values. The HACC Cultural Planning Strategy is currently being evaluated. Cultural Diversity Plan for Victoria’s Specialist Mental Health Services 20062010 This plan provides a framework for improving mental health services’ accessibility and responsiveness to Victoria’s culturally and linguistically diverse communities. The Victorian Government has also endorsed the Framework for Implementation of the National Mental Health Plan 2003-2008 which has four key approaches relevant to culturally sensitive care: a population health approach acknowledging the influence of migration experience and culture as risk and protective factors in mental health. Departmental regional offices are responsible for regional planning.Cultural Action Plans. The Culturally Equitable Gateways Strategy was initiated in 2003 as CALD communities were identified as being under-represented in core HACC services in relation to their numbers. not in the principles. The national initiatives implemented by Department of Human Services include the National Standards for Mental Health Services and the National Practice Standards for the Mental Health Workforce. legislative base which provides a compliance base or a self regulatory (nonmandatory) framework. These include: understanding clients’ needs. and 34 . The differences lie. as central to quality mental health care. This Strategy was reviewed in 2007 and overall.2 Discussion The Victorian Government multicultural affairs policy framework shapes the internal policies and strategies of the department. This evaluation will determine future directions for cultural planning in the development of HACC policy and service delivery.

regional or rural). it is instructive in that it points to problems relating to implementation of cultural competence. problems with cultural sensitivity of services. The exploration of the answers to this question is complicated and patchy. access to language services. The reporting against HSCDP has resulted in strong compliance although without a mandatory base. again with National Service Standards and legislative framework identified that cultural responsiveness and access was a major issue which led to further initiatives such as The Culturally Equitable Gateways Strategy. Work has been commissioned to develop consumer participation indicators. better workforce planning and stronger monitoring and reporting (DHS. variation in the level of detailing of strategies and actions. Onerous processes can be a prohibitive factor in the continuous improvement cycle. 35 .6. and different approaches to cultural diversity responsiveness based on geographical location (for example. 2006c). It is clear from the above mapping processes that there are many complex reporting and planning arrangements within the department and providers may see these as onerous and time-consuming. The planning and reporting processes. responsiveness of clinical and psychiatric disability rehabilitation and support services were not responsive to needs of CALD clients (Department of Human Services. Similarly in the mental health area. The cultural diversity elements of EQUiP 4 are presented in a very broad manner 1. disability services) that has long had mandatory processes. The HACC program. four key issues were identified as problematic in these reporting arrangements: • • • • variation in the duration of HSCPDs ranging from 1-3 years. While health service are assessed by the Australian Council on Health Care Standards using the tool EQUiP 4 Accreditation standards and guidelines. 2004). metropolitan. In a consultation held in 2007 by department. A consultation undertaken by the department in 2003 identified major problems including: better access to information. can inadvertently lead to its resentment and it being seen as just another task to be ticked off as being done. there is no mandatory elements relating to cultural diversity service standards. On the other hand. Additionally there is little or no research about CALD consumer experiences of health services. while attempting to ensure consideration of cultural diversity. practice and scope of cultural diversity committees. 2008a:7). While this consultation precedes the adoption of The Disability Services Cultural and Linguistic Diversity Strategy.3. reporting and monitoring in a field (that is. A comparative look at the differences in reporting within the department begs the question of mandatory reporting against self assessment.• internal and external resources available to services to support cultural diversity planning and reporting processes. with legislative and mandatory reporting arrangements and Service Standards. HSCDP does not have legislative and service standards in the same way. Eighty-four out of 88 health services across Victoria submitted plans to the Statewide Quality Branch relating cultural diversity outcomes (Department of Human Services.

The key findings were: • • • • • • • • • • • • • • • • • • • linking HSCPD with other strategic and management planning. need for clarity about whose role it is to evaluate if improvements to be made. need for a model of consumer participation that works with CALD communities. clearer planning and reporting processes and who has responsibility for it. However at this forum. reframing the plans under patient safety and risk management and performance management. improvements in language services. need for leadership on cultural diversity within the department senior executive champions. need to know how to access to expertise. needing to build the status of the issue within competing priorities. need for sufficient support and resourcing in planning and reporting. A forum to review Health Service Cultural Diversity Plans titled Present PracticeFuture Opportunities Forum endorsed the value of cultural diversity planning processes as a way to keep the focus on CALD issues in health services. streamlining reporting arrangements with auditing and quality improvement processes in the Department of Human Services. benchmarking and setting standards. Strategic planning timeframes (there should be a three or even five year plan not just a one year plan).this is offered in a range of languages. better partnerships with community and internal sharing of information. no baseline data and a lack of consistent data and information sources within the department. difficulties of measuring outcomes.The Victorian Patient Satisfaction Monitor (VPSM) collates surveys regarding peoples’ experiences in health services through a questionnaire mechanism . 36 . challenges of a whole-of-organisation approach within a complex departmental environment. particularly that there is no baseline data. and making staff training mandatory and the need for standards on training. linking various cultural diversity planning processes. need for feedback on reporting and planning. communication processes within the health service. numerous planning and reporting challenges and issues were identified.

accreditation and quality systems. health outcomes. 2008a). King et al (2008 pp. The department has commissioned work to develop a second set of consumer participation indicators under the ‘Doing it well vs. casting doubt on self reporting and the need to make planning and reporting more effective. Where examples have been found. Searches were conducted in the web pages of the Commonwealth and state government departments of health. human services and multicultural affairs. However. 7. A measurement of this intervention would be that procedures would be completed and published. Systems of reporting vary from agency to agency and across the states in Australia. This indicates dissatisfaction with existing reporting processes.. The Plan is aimed at achieving three consumer based outcomes and outline strategies for the achievement of these outcomes: • People of non-English speaking background are aware of the health services which are available to them and the health system which provides these services. The following represents an attempt to map the current state of cultural diversity in Australia in relation to health. A reference to reporting by health services was noted in the Action Plan for the Royal Adelaide Hospital (2007-2010:13) which indicated that: Procedures would be developed to respond to complaints by patients about staff who are culturally insensitive or discriminatory. not for us’ policy framework. A desk based literature review was not able to adequately identify internal reporting arrangements as many evaluations and reports are not made public. Additionally there was a call for indicators. and legislating for language services. The NSW Government and NSW Health point out that they are committed to ensuring public health services meet the needs of all NSW residents. Due to the absence of an appropriate evidence base available in the public domain. regardless of their cultural origins or their English skills. 251) noted that out of 501 hospitals surveyed in the US in 2006 fewer than one in five hospitals that collected race/ethnicity information used it to assess disparities in quality of care. they have been about one-off initiatives or highlights of a promotional nature. or patient satisfaction. and that reporting would be ongoing. the picture. making analysis of their effectiveness difficult.3 Selected Commonwealth and State Policies and Reporting Frameworks Information in relation to current systems for reporting disparities for minority groups of health care consumers as they relate to health systems is very difficult to locate in the Australian context. At present the New South Wales Health Department has published the guide to Health Services for a Culturally Diverse Society: Implementation Plan .In this forum there was a call from practitioners for ‘mandating’ managers on performance and reporting more effectively and with correct reporting processes on cultural diversity outcomes. can be described as patchy and incomplete. Much of the multicultural affairs reporting is focused broadly on the government achievements against their policies and is not specific enough. at best. 37 . embedding cultural diversity within risk. standards and benchmarking to establish stronger systems to measure progress and cultural diversity outcomes in more concrete way (Department of Human Services.

These reports highlight key initiatives and are often promotional in nature. ( Strategic Directions in Refugee Health Care in NSW (1999). 2. Guidelines for the Production of Multilingual Health Resources by Area Health Services. However there is no information on how this accountability is implemented or monitored. the government has adopted a Substantive Equality Framework which agencies have to report against. and 6. The NSW Health Plan has seven strategic objectives including meeting consumer needs and developing their workforce.nsw. programs and health services which recognise the cultural diversity of the people of NSW. These reports are whole-of-government reporting on multicultural affairs and take place within four broad headings. Caring for Mental Health in a Multicultural Society: A Strategy for the Mental Health Care of 5.• • • People of non-English speaking background make judgements about the health system and their own needs and articulate these to the appropriate organisational component within the health 4. All public health system employees are required to follow these guidelines that are explained in the following documents: 1. The policy framework set out a key role for the public sector in addressing systemic discrimination by: 38 . The South Australian Government Department of Health identifies the notion of ‘cultural accountability’ in their Primary Health Care Policy Statement 2003-2007.aspx?tabid=62) In Western Australia (WA). respecting and being accountable to the unique cultural needs and values of diverse reflects an attention to cultural diversity (http://www. Circular 94/10: Standard Procedures for the Use of Health Care Interpreters (1994). and commitment to equal opportunities that reflect the cultural diversity of NSW. 3. The NSW reporting and monitoring of multicultural affairs takes place under the Ethnic Affairs Priorities Statements (EAPS). Health Services for a Culturally Diverse Society: An Implementation Plan (1995). Information on the reporting mechanisms for these or what standards are used for reporting was not identifiable from their public information systems. In their website. The Statement defines cultural accountability as responding to diversity by recognising. Judgements made by people of non-English speaking background about health system and their own health needs are included in the policies and plans of the health system. NSW Health Department and NGOs funded by NSW Health (2001). Annual Report 2007 (pp. 2002). People from Culturally and Linguistically Diverse Backgrounds (1998). The broad criteria are not sufficient to gauge what indicators or standards are being used and it cannot be considered a measurement tool. NSW Health promotes: • • • policies and procedures to allow equal access for all people to health Health systems services are accessible and appropriate and used by people of non-English speaking background (NSW Health.

move away from the usual generic ‘one size fits all’ model of reporting. it has developed the Queensland Health Strategic Plan for Multicultural Health 2007-2010 . Rather outcomes are negotiated and agencies report against those achievements they negotiated.• • • ensuring that policies respond to individual and communities’ different needs and priorities. to one which suits the individual needs of agencies.wa.equalopportunity. providing services that meet the needs of different Indigenous and ethnic groups. The WA Government reporting framework has been designed as an integral part of the change process to: • • • • • enable agencies to make gradual transition towards the aims of the Policy Framework for Substantive Equality. and having effective work practices including recruitment and retention policies. Queensland Health has been making progress towards embedding cultural diversity into its service and program design and delivery. They have a number of policy frameworks within their portfolio including: • • • Queensland Health Multicultural Policy Statement Queensland Health Language Services Policy Statement Queensland Health NESB Mental Health Policy Statement These policies set out the principles of access and equitable health service delivery to CALD communities. make reporting easier. The implementation framework is governed by a number of plans .gov. In addition. and increase accountability in relation to providing services to people of different Indigenous and ethnic backgrounds (http://www. In Queensland. They identify a series of action that build cultural competence of the health system such as: • • • • • • • Focus on refugee health Workforce development Training of professionals Building sustainable language services Monitoring and evaluation strategies for particular program areas Raise Queensland Health’s profile in CALD communities Work on culturally appropriate complaints mechanisms 39 . The interesting element of this model is that it does not implement a generic framework across all agencies to report against. develop the Policy Framework aims in a supportive and learning environment. The Statewide Health Services Plan 07-12 recognises the health needs of people from CALD backgrounds and identifies that improving access to health services will be considered in Area Health Service and other planning processes. The reporting on the cultural diversity planning takes place through the Queensland Health Multicultural Action Plan 2006-2007 which is a whole of government process on reporting on multicultural

the strategy remains the same. The reporting criteria for AGSFA are also broad and include: • • • • • Responsiveness—the extent to which programmes and services are accessible. delivery. In 2007. (http://www. the department published the Access and Equity annual report. Between 1996 and 2005. fair and responsive to the individual needs of clients. The Department of Immigration and Citizenship traditionally monitored and reported against access and equity considerations. 2.qld.pdf). This framework was adopted to promote fairness and responsiveness in the design. which reported on progress in implementing the Charter of Public Service in a Culturally Diverse 40 . This is guided by four broad areas: • • • • Knowledge and Awareness Skilled Practice and Behaviour Strong Customer or Community Relationships Equity of Outcomes This framework is useful in that it identifies areas of focus within organisational performance related to culture. Accountability—the effectiveness and transparency of reporting and review mechanisms. Since the election of the Rudd Labour the Charter was replaced by a new strategy. 4. These are: 1. Communication—the openness and effectiveness of communication channels with all stakeholders. monitoring and evaluation of government services in a culturally diverse society. The Australian Health Ministers Advisory Council (AHMAC) endorsed the National Cultural Respect Framework for Aboriginal and Torres Strait Islander Health in 2004. AGSFA reverted to the Access and Equity name. Leadership—a whole of government approach to management of issues arising from Australia’s culturally and linguistically diverse society.immi. A number of strategies are suggested under each of these categories for implementation and reporting. Queensland Health has established a multicultural health site and has identified a five-year strategic plan with key actions against it. The reporting takes place against four broad criteria of the Multicultural Queensland rnment_2006/_pdf/accessible_government_appendixa.pdf) An examination of cultural competence performance reporting in Indigenous Affairs shows other practices of planning and reporting. however. Strengthening Multiculturalism Productive Diversity Supporting Communities Community Relations and Accessible Government Services for All (AGSFA). there has not been a review of the policy framework for multiculturalism. In 2008.• Develop and disseminate a guide on information dissemination • Establish a state-wide model of multicultural mental health coordinator positions (http://www. 3.

timeliness. effectiveness. separation of quality improvement. Reporting frameworks often relate to the principles relating to cultural diversity outlined above. review and practice development Aboriginal workforce development Monitoring and evaluation Planning occurs through an impact statement rather than a generalised plan. education. Monitor number of cultural partnerships. The standards of data collection and assessment of impact are often inappropriate (for example. policy and program development and links to other accountability mechanisms. Multiple reporting processes. Reporting and monitoring systems are complex and depend on many organisational developments. A glance at current practice in Australia indicates that what is happening is fragmented. for example. utilisation of reports in improvements in service. efficiency and equity. For example. He identifies that improving the quality of health care encompasses six aims: safety. The impact of the intervention is often difficult to isolate from other factors. 41 . Conduct periodic Aboriginal patient satisfaction surveys. randomized control trials). patient-centeredness. The reporting process is also fraught with complications and these apply to the department and other government agencies.Each jurisdiction is to develop its own reporting frameworks. which are not well integrated. patient safety. Smith (2002) advocates that monitoring for cultural diversity and migrant/minority health care issues require it to be framed as a quality issue. other risk management. Consult local Aboriginal community representatives on the cultural appropriateness of local health services (Government of WA b). Their effectiveness is dependent on factors on a number of factors including: planning processes. cultural education sessions and services reviews by directorates and health services. None of these are specific enough to determine measures of progress. Bischoff (2003) identifies that it is important to connect systems of reporting with quality of care. Instruments of reporting often need to be reworked to address linguistic and cultural issues. This calls into question whether more specific standards and indicators are needed. A lack of standard definitions complicates comparability between government agencies and health services. Assess trends in Aboriginal hospital admission data. The key issues include: • • • • • • Lack of quality baseline data. the Western Australia Government Office of Aboriginal Health has developed a Cultural Respect Framework which has four key parts: • • • • An Aboriginal impact statement for policy and program development Services reform through cultural partnerships. area health service and local level. specificity of the criteria for performance. resources. patient satisfaction and other processes. In terms of monitoring and evaluation the framework lists potential actions as: • • • • • Monitor use of the Aboriginal impact statement in program and policy proposals at divisional.

Integrating cultural competence reporting into broader national health care objectives. is a challenge but one that should be urgently addressed. 42 .

The Lewin Group (2002) undertook a project with the aim to develop an analytical framework for assessing cultural competence in health care delivery. and to measure progress against. training relating to cultural awareness and competence for health services. particularly use of interpreters and/or bilingual providers. The resulting framework is named as a Cultural Competence Assessment Profile (the Profile) that is a tangible and targeted approach 43 . the organisation. What are the indicators? 3. Standards can focus on different levels of the health care system: the patient. use of linguistically and culturally appropriate health education materials. feasibility and practical application of the framework and its indicators. They identified a number of strategies including: • • • • • recruitment and retention of CALD staff that reflect the diversity of client groups. the region or the country. set out the knowledge and skills that an individual or an organisation must have to fulfil the requirements for standards of performance. Anderson et al (2003) undertook a review of interventions that were designed to take into consideration the health care needs of CALD clients. language services. identify specific indicators. The evaluation of outcomes of before-after or control group studies indicated outcomes relating to improvement in client health status. explicitly and by implication. What standards should be used? 2. reliable and consistently perform the way they were intended to. However. This is because the conditions for error and harm can occur at all levels. utilisation of services and levels of satisfaction. This makes reporting requirements within and between health departments difficult to ascertain. Standards can work towards mitigating risk and achieving quality outcomes. How is progress against the standards and indicators to be measured? Standards are published documents setting out specifications and procedures designed to ensure products. They establish a common language which defines quality and safety criteria (Standards Australia).8. STANDARDS OF CULTURAL COMPETENCE FOR HEALTH SERVICES A lack of national standards exists in relation to the provision of culturally and linguistically appropriate services in health services. the practitioner. Determining what outcomes have been achieved against standards work well when they are aligned to indicators which are appropriate to measure progress. improved service utilisation by CALD clients and changed treatment regimes for CALD clients. They also establish protection for consumers. provide opportunity for improvement and innovation and can act as regulatory mechanism. This highlights the key questions for this section poses a number of key questions: 1. the study did not find sufficient evidence to determine the effectiveness of any of the interventions. client satisfaction with care. and assess the utility. Standards. and provision of culturally relevant healthcare settings. services and systems are safe.

The Evaluation and Quality Improvement Program (EQUiP 4) provides a framework for safety and quality for health services. each domain has focus areas and focus areas have indicators (for example. EQUiP4 sets out standards in three broad areas. In addition. These cover the standards relating to continuity of care. 8. The sites emphasized the importance of assessing the domain of organisational values as the necessary precursor to culturally competent performance. but rather a continuous process that is emphasized and integrated in an organisation’s overall assessment activities. staff development. Clinical. appropriateness. Commonly recognised providers of health care standards and/or accreditation services include the Australian Council for Health Care Standards (ACHS). It is a selfassessment undertaken by health services on an annual basis with biennial on-site surveys by external accreditation surveyors. Key observations of this project are: • • Assessment is Not an Isolated Event assessment of cultural competence should not be considered an isolated event. effectiveness. structure. organisational infrastructure. Importance of Assessing Institutionalisation: there is a need to assess the ‘institutionalisation’ of cultural competence in an organisation. quality improvement and risk management. management and business functions. human resource 44 .1 Australian Standards There are a number of standards that provide the framework for health and allied health service provision in Australia. It can also be used in structured quality assurance and other performance measurement activities such as mandates and standards. governance. the site visits supported the credibility of the Profile’s focus areas and specific indicators. • The authors suggest the profile can assist organisations to identify the critical elements of measuring cultural competence. safety and consumer focus. planning and monitoring/evaluation. and services/interventions. Validation of the Components of the Profile: the exploratory process for this project give credence to the Profile’s seven evidence-based domains as appropriate performance areas for assessing cultural competence.for conducting organisational assessments. the extent to which cultural competence is an integral part of the organisation’s service. access. The domains include organisational values. it is potentially useful for organisations at different levels of cultural competence development due to its flexibility organisations can pick and choose aspects that most suit them. The Standards set by the Australian Council of Healthcare Standards (ACHS). that is. communication. Support and Corporate. process and output). b) focus areas within domains. the Quality Improvement Council (QIC) and the International Organisation for Standardisation (ISO). namely. Since the development of the Profile involved action research. and c) indicators relating to focus areas. The profile can be useful to organisations serving a single and multiple ethnic groups. ACHS’s mission is to ‘improve the quality and safety of health care’ through an independent assessment process. It has three major components: a) domains of cultural competence.

The MHS delivers treatment and support in a manner which is sensitive to the social and cultural’ (http://www.achs. excellence and leadership.3 which states ‘The organisation makes provision for consumers / patients from culturally and linguistically diverse backgrounds and consumers / patients with special needs. The National Standards for Mental Health Services outlines a standard which specifically relates to cultural There are 14 mandatory implementation. Documented policies and procedures exist and are used to achieve the above criteria.vic. Standards relating to cultural diversity are listed under Consumer Focus (non-mandatory) in Article 1. A standard on cultural awareness is that ‘the Mental Health Services (MHS) delivers non-discriminatory treatment and support which are sensitive to the social and cultural values of the consumer and the consumer’s family and community’ (http://www.25). • • 45 . and safe practice and environment. information management. (http://www. population The MHS employs staff or develops links with other service providers/organisations with relevant experience in the provision of treatment and support to the specific social and cultural groups represented in the defined community.mandcriteria. Some examples are provided under each of these elements. none specify cultural diversity. The accompanying guide notes that health services should develop policies and systems to address: • • • • • Understanding people and their needs Systems to understand and analyse changing demographics Providing relevant and accessible information An appropriately trained workforce Meeting the specific needs of different communities. leadership and management.pdf) These standards are provided within a continuous improvement cycle of awareness. • • • • • These standards are mandatory and have a specific reporting requirement as noted above. The MHS considers the needs and unique factors of social and cultural groups represented in the defined community and involve these groups in the planning and implementation of There are a number of criteria listed for these standards: MHS staff have knowledge about the social and cultural groups represented in the defined community and an understanding of those social and historical factors relevant to their current circumstances. The standards are divided into mandatory and non-mandatory.pdf. values and cultural practices of the consumer and their carers.pdf) These standards are relevant to HSCDPs as they cover similar criteria about culturally sensitive service provision. Implementation and reporting for HSCDPs can be an important element of meeting accreditation requirements. The MHS monitors and addresses issues associated with social and cultural prejudice in regard to its own staff. research.

3. The Royal College of General Practitioners have developed standards for health services in Australian detention centres. The Instrument has a number of specific questions relating to cultural diversity: Objective 1: How can your agency demonstrate that access to services by special needs groups occurs on a non-discriminatory basis? Objective 4: How does your agency ensure that the consumers’ cultural needs are taken into account when providing care/support? (http://www. (http://www. however. a number of strategies have been developed. 2. The standards are assessed using self assessment and joint assessment methodologies with the relevant State Department.pdf) A scan of the literature was not able to identify an evaluation of the practice of implementation of these standards or their effectiveness for culturally sensitive care. a continuing need to improve health outcomes for people from culturally and linguistically diverse backgrounds. Confidentiality and Access to Personal Information Complaints and Disputes Advocacy. The HACC National Service Standards were introduced in 1991 to provide agencies with a common reference point for internal quality controls by defining particular aspects of service quality and expected outcomes for consumers in seven key areas: 1.vic. Access to Services Information and Consultation Efficient and Effective Management The current Victorian Standards for Disability Services 1999 (the ‘Standards’) represent the minimum operational standards for government and non-government disability support services in The guidelines are not meant to be prescriptive but rather are intended to provide general guidance to agencies and service quality assessors in collecting the views of consumers as part of the appraisal of service These standards are assessed by the HACC National Standards Instrument and Guidelines covering the seven criteria listed above. They identify that the criteria in these Standards relate to systems and processes that require extra attention to ensure the 46 . 5. Planned and Reliable Service Delivery The Evaluation Report of the Second Mental Health Plan noted that there remains. 6. The Standards for Disability Services in Victoria set out the expectations of better practice for the delivery of services and supports to people with a disability.• The MHS monitors its performance in regard to the above criteria and utilizes data collected to improve performance as part of a quality improvement process. including: • • • • Consumer assessment Service delivery self assessment Management self assessment Development and implementation of quality plans. 7. To ensure that the standards are implemented by organisations.

Individual While the context of health service delivery in detention centres is very different from the traditional health service While not linked directly with health systems standards The Aged Care Standards and Accreditation Agency is the body appointed by the Department of Health and These include: • • • • • • • • • Informed patient decision (Criterion 1. Management of Health Information Equipment for Comprehensive Care Clinical Support Processes. A number of standards are developed including: • • • • • • • • • • • • • Access to Care Information about the health service.3). (http://www. Of interest is the standard 3. There are a number of standards specified in the accreditation of residential care facilities. Outcome Continuity of comprehensive care (Criterion 1. as the accreditation body residential aged care facilities.1. Continuity of Care. To assist the implementation of this standard the Department of Health and Ageing has initiated a Program titled Partners in Culturally Appropriate Care (PICAC) to ensure the special needs of older people from diverse cultural and linguistic backgrounds are identified and addressed.6. One of the key elements of this is the funding of the Centre for Cultural Diversity and Ageing which provides both 47 .1) Confidentiality and privacy of health information (Criterion 4.1) Respectful and culturally appropriate care (Criterion 2.1.5.) is respectful and culturally appropriate care. the issues identified in the report are transferable to other CALD populations in relation to care delivery.2.1) Continuity of the therapeutic relationship (Criterion 1. titled Resident Lifestyle. beliefs and cultural and ethnic backgrounds are valued and fostered (http://www. The standard defines the general principle of the standard and lists 10 expected outcomes.provision of high quality and safe care to patients within immigration detention centres.4.5. This standard has a set of indicators which will be described in the next section. Coordination of care Content of Patient Health Records Collaborating with Patients Safety and Quality Education and Training Service Management. under the Aged Care Act (http://www.3) Clinical autonomy for medical.2) Engaging with other services (Criterion 1.1. Of particular interest is the subset of Collaborating with Patients Standard (2.2) Interpreter services (Criterion 1.1) Transfer of health information (Criterion 4.racgp. Health promotion and prevention of disease. Diagnoses and management of specific health problems. clinical and allied health staff (Criterion 1.8 is Cultural and spiritual life .

culturaldiversity. 11. the Department of Health and Human Services’ Office of Minority Health (OMH) published standards for culturally and linguistically appropriate services for healthcare organisations. Within this framework. and linguistic population groups that experience unequal access to health services. they are especially designed to address the needs of racial. finalised standards must be more than mere ‘guideposts.2 International standards Culturally and Linguistically Appropriate Services (CLAS) are the US set of recommendations for national standards with an outcomes-focused research agenda. 9. (http://www. 5. The standards are intended to be inclusive of all cultures and not limited to any particular population group or sets of groups. In the submission to the CLAS standards a number of concerns were expressed by different agencies relating to implementation and Guidelines—CLAS guidelines are activities recommended by OMH for adoption as mandates by Federal. There are 14 standards. the final standards should be issued as enforceable regulations.’ ‘To have any effect in practice. and 7).omhrc. In 2001. and national accrediting agencies (Standards 1. (refer to Appendix 3 for details) which are organised by themes: • • • Culturally Competent Care (Standards 1-3) Language Access Services (Standards 4-7) Organisational Supports for Cultural Competence (Standards 8-14). These considerations are central to cultural competence practice and include a range of perspectives. 6. and 13). When a guideline or standard is strictly mandated and regulated. 12. These standards were an initial move to provide structure to what constitutes culturally appropriate healthcare services. 10. we fear many health care organisations and providers will not prioritize 48 . 8. there are three types of standards of varying stringency: • • • Mandates—CLAS mandates are current federal requirements for all recipients of federal funds (Standards 4. The CLAS standards are proposed as one means to correct inequities that currently exist in the provision of health services and to make these services more responsive to the individual needs of all patients/consumers. ‘We do not believe that culturally and linguistically appropriate health care services are an area of health care that should be highly regulated. ethnic. 3. State. Without an enforcement mechanism to support the final standards. Recommendations—CLAS recommendations are suggested by OMH for voluntary adoption by health care organisations (Standard 14). support and service provider support (http://www. all possible opportunities for flexibility and innovation are eliminated.’ To the extent possible. This approach is not in the best interests of the patient or customer needing the 8.

Integrating cultural competence into broader organisational goals and programs was identified. evaluation mechanisms and other resources required to implement and comply with the standards. Also questions are raised about whether standards can. qualified personnel. The review shows there are no accepted standards or method for reporting on safety and quality in health care organisations. ethnicity.’ ‘Issues related to incentives. costs. often accepted as providing an indicative measure of quality. The conference notes that the two greatest challenges to implementing organisational cultural competence strategies remain persuading leadership and staff. they would likely overwhelm most hospitals’ and physicians’ resources — both time and money’ (US Department of Health and Human Services 2001). prevent ‘risk’ or guarantee the quality of care. the standard is very broad and does not provide sufficient guide for agencies for implementation.3 Discussion As can be seen from these standards. It is assumed that standards setting results in compliance. The US Institute of Medicine (2001) Crossing the Quality Chasm notes that a system is high quality if it provides care that does not vary because of personal characteristics such as gender. training. However. adequate reimbursement. The implementation of CLAS has met with challenges.linguistic and cultural competence and our communities will continue to lack access to quality health care. county health departments. and socioeconomic status. Whenever a standard is set. There are also a number of issues that arise from setting and implementation of standards. (http://www. and Measurement. representatives of health care organisations— clinics. reimbursement and other administrative concerns and if CLAS standards are applied if applied literally. However. however. as the key strategy. 2002. and finding resources. in reality.’ ‘The American Academy of Pediatrics agrees with the intent of the DHHS recommendations for cultural competence standards. Gaining support for organisational change was identified as ‘very challenging’. these are not specific enough. While some standards have guides or specified outcomes. As noted by the Australian Council for Safety and Quality in Health Care (2003: 6) it should not be assumed that the higher the standards set by standard-setting agencies the better compliance would be. cultural diversity is either not included or included as a subset of other standards. some organisations will decide that the costs of 49 . Data. but many Health Services felt that the national standards for CLAS provided a useful guide the interventions they are implementing. geographic location. These are reflected in a number of forums and documented in the Third National Conference on Quality Health Care for Culturally Diverse Populations: Advancing Effective Health Care through Systems Development. the Academy has concerns regarding the availability of education. The Conference resolved that the CLAS standards can guide organisational change and assist with the implementation of cultural competence in a host of health care settings. Accreditation 8.diversityrx. Where it is included. and for-profit and nonprofit managed care organisations—reported on several years of experience implementing cultural competence activities. hospitals.

compliance exceed the costs of non-compliance. In the various standards explored above, the levels of compliance with the standards related to cultural diversity remains unknown. The expectation of stakeholders who are involved in the accreditation and standards process means that there is more scrutiny of the standards and the expectation of more efficient and streamlined systems to cater for diverse Health Services. In relation to cultural competence in health care there is the debate on whether a national framework should be developed and publicly reported each year against standards and benchmarks. The Australian Council for Safety and Quality in Health Care notes a number of issues for consideration, especially in relation to accreditation and the standards that are developed for accreditation purposes. The pertinent issues are categorised and discussed below. Standards development processes There are a growing number of standards and standards setting bodies in health care, raising concerns about the cost and quality of standards setting processes. There is little coordination to prevent duplication of standards across organisations and service delivery areas, as well as identification of new priority areas. Accreditation agencies that develop their own standards fund that activity (sometimes with ad hoc government assistance) through membership fees from organisations that they will subsequently survey for accreditation. This may create competing imperatives relating to the rigour of the standards versus the subsequent cost of compliance to members. There is a variable level of involvement of consumers or other independent stakeholders in standards setting processes. Whether consumers should be involved in the accreditation or assessment processes; what level of involvement should they have are issues of contention. The Working Group strongly believes that consumers should be involved at all levels including the governance structures of any accreditation/assessment system. Quality of standards Defining a ‘safe health system’ is not an easy task and to date has not been done sufficiently well. The underpinning philosophy of standards varies widely. For example, some define minimum acceptable structures, processes or outcomes, while others are goal oriented/ideal statements. Standards for health care have traditionally focused on organisational structures and processes. They are moving towards an outcome orientation but have not yet comprehensively addressed patient safety. There is no single set of minimum or core standards for health care. Accreditation processes Whilst there are some incentives (including funding incentives), participation in accreditation programs is largely voluntary. Informed consumers are concerned that accreditation based on an organisation’s commitment to continuous quality improvement may overlook the possible inadequacy of the starting point from which improvement is being encouraged. There is little being learned by the health care system from the wealth of data collected through the accreditation processes. There is a variable level of involvement of consumers in accreditation or standards development.


Organisational impact There are strong imperatives to reduce the administrative burden of accreditation. Stakeholders are concerned that accreditation is potentially diverting resources from strategies aimed at directly addressing quality and safety concerns. There is particular concern about requirements to be accredited by multiple service providers against multiple sets of standards. In addition, the burden of accreditation on small facilities may be disproportionate to their resources and capacity, and to the outcomes gained from accreditation. In addition to requiring accreditation, most state governments and some third party purchasers require evidence of compliance with specific system and outcome criteria, creating a significant extra burden for health care organisations. The question is whether a more robust accreditation system could completely meet the requirements of these stakeholders, thereby alleviating the administrative burdens created by their additional compliance and reporting requirements. Organisations want a system that reassures the board, management, consumers and clinicians that their facility is providing care of an acceptable standard of safety and quality. ( The US National Quality Framework argues that cultural competence cannot alone deliver outcomes unless it is embedded across all aspects of an organisation. One of the conclusions of 2002 The Third National Conference on Quality Health Care for Culturally Diverse Populations in relation to advancing effective health care through systems development, data, and measurement was that cultural competence must align its objectives with broader quality-of-care initiatives to strengthen its position in the national health care agenda. The implication of this is that cultural diversity issues need to be reconsidered as part of a broader quality of care processes of the department including risk management, patient centered care and appropriate data collection including consumer feedback data ( The National Quality Framework also notes that a standardised core set of performance measures based on cross-cutting quality issues that is broadly applicable across all healthcare settings should be adopted (NQF, 2002).


Indicators are instruments which are used to measure or determine what is happening over time, measure progress made or establish benchmarks for judgement. Indicators are an important element of performance measurement to strive for good practice and ensure continuous quality improvement. A social indicator was defined by the Organisation for Economic Cooperation and Development (OECD) as a ‘direct and valid statistical measure which monitors levels and changes over time in a fundamental social concern’ (OECD, 1976:14). The OECD uses social indicators for two purposes: first to describe social developments and second to determine how effective society and government are in altering social outcomes. This is to be contrasted to indicators linked to performance management techniques that measured achievements in terms of outputs and targets (Armstrong et al, 2002:3). The terms outcome and impact are often used interchangeably to denote what is being measured. ‘Outcomes reflect the net effect of the program on the target population. They show the impact the program has on the original problems or identified need, who receives assistance, and the impact of the program on people’s well-being’ (Department of Premier and Cabinet Victoria 1988:16). Beneforti and Cunningham (2002) identify three types of indicators: • • • Program viability and sustainability indicators Participation indicators Outcome indicators

Program viability and sustainability indicators measure aspects of program functioning including: turnover; funding levels and stability; community consultation and support; involvement, employment and training of local people; succession planning; adequacy of facilities and equipment; and access to these facilities and equipment at critical times. These indicators enhance understanding of the processes which can lead to positive outcomes (and therefore how they could be repeated). Participation indicators provide a summary measure of community participation in activity or initiative, and where relevant, the participation of target groups (for example, women, adults, youth, and refugees). Outcome indicators provide insight into changes in social areas more broadly. The most comprehensive set of indicators to measure cultural competence has been developed by the Lewin Group in 2002. The Health Resources and Services Administration (HRSA) and the Office of Minority Health (OMH) commissioned the Lewin Group to develop indicators of cultural competence. The resulting Assessment Profile included the domains that provide the underlying construct of cultural competence within a healthcare organisation, and the critical areas in which cultural competence should be evident or manifest in an organisation. The Assessment Profile had the following eight domains: Organisational Values: An organisation’s perspective and attitudes with respect to the worth and importance of cultural competence and its commitment to provide culturally competent care.


the Migrant Friendly Hospitals used the following indicators to measure staff training and to measure how staff are able to better handle cultural encounters (http://www.pdf): • Feasibility could be demonstrated for example. and other features related to the organisational context in which services are provided. and operational cultural competence planning that is informed by external and internal consumers. financial resources.Governance: The goal-setting. the response to care. acceptability among staff varied in the hospitals but altogether a total of 149 staff members participated. Process indicators are used to assess the content and quality of activities. and health related services in a culturally competent manner. Output indicators are used to assess immediate results of culturally competent policies. Staff Development: An organisation’s efforts to ensure staff and other service providers have the requisite attitudes. facilities and equipment. procedures. knowledge and skills for delivering culturally competent services. programmatic. and interventions in the practice of culturally competent care and in support of such care. and internally among staff. For example. Services/Interventions: An organisation’s delivery or facilitation of clinical. 53 . information systems.mfheu. public health. Organisational Infrastructure: The organisational resources required to deliver or facilitate delivery of culturally competent services. and the results of care. Structure Indicators are used to assess an organisation’s capability to support cultural competence through adequate and appropriate settings. and infrastructure. These domains (refer to Appendix 4 for a further breakdown of these domains) may be considered the dimensions in an agency to which standards can be set. Communication: The exchange of information between the organisation/providers and the clients/population. methods. Planning and Monitoring/Evaluation: The mechanisms and processes used for: a) long and short-term policy. These are then measured by specific indicators which the Lewin Group divides these into four types. The Lewin Group indicators have spawned the development of a range of indicators by different organisations in different domains. Intermediate outcome indicators are used to assess the contribution of cultural competence to the achievement of intermediate objectives relating to the provision of care. instrumentalities. and other oversight vehicles an organisation uses to help ensure the delivery of culturally competent care. and b) the systems and activities needed to proactively track and assess an organisation’s level of cultural competence. policy-making. governance and administrative structures. including staffing. in ways that promote cultural competence. and services that can lead to achieving positive outcomes.

• •

Quality was operationalised in terms of the following dimensions: content, structure, amount of training units, qualification of trainers, composition of participating staff, management support, systematic needs assessment on the department level, integration in ongoing quality assurance etc. Effectiveness could be confirmed by improvement of staff’s self-rated awareness, knowledge, skills and comfort level concerning cultural diversity issues, as well as by increases in interest levels regarding cultural competence and in staff's selfrated ability to cope with work demands. Cost-effectiveness: external training costs were low, but developmental costs rather high, despite personal costs being mainly covered through voluntary work. Sustainability: training was recognised as an effective way to equip staff with important competencies and will be continued but modified in all participating hospitals.

The Cultural Competency Standards and Self Assessment Tool Manual developed by the Multicultural Forum of Mental Health Practitioners (2005:pp.s 6-10) also developed broad standards and indicators, as outlined in the following table 1.
Standard Service planning Indicators Strategic Business Plan demonstrates commitment Policy for ensuring delivery of culturally appropriate services to all cultural groups in the service region Incorporated cultural competence principles in its recruitment processes for all positions at the service Gazetted specialist multicultural liaison staff position CALD representation on all internal committees Staff representatives on various CALD community organisations Distributed information in English and in key CALD languages Ensured clinicians are aware of existing alternative/complementary providers for example traditional healers; and key individuals in community to consult with concerning religious beliefs influencing treatment Informed CALD consumers about their rights and responsibilities in accessing and using service Promoted awareness of its programs in appropriate languages and places Developed policies and procedures to address and accommodate culture-based needs of CALD consumers Accessed accredited interpreter services when needed Conducted assessment and diagnoses by formally qualified and cultural competent clinicians

Collaboration with Key Stakeholders

Equitable Access to CALD people


Some indicators have been para-phrased for the sake of brevity.

Language Services Policy

Clinical cultural competence Training

CALD Consumer and Care Participation

Research and Development

Fiscal Support

The service has a Language Services Policy Negotiated with Interpreter Service agency to ensure accredited interpreters who are trained in health issues and terminology Used accredited mental health trained interpreters when required Provided staff training on use of interpreters Sought to develop a staffing profile which reflects the cultural diversity of the wider community Ensured all staff undergo the state-endorsed clinical cultural competence training program within the first 12 months of employment Made available culturally validated assessment instruments or tools Incorporated cultural competence into staff orientation and performance review requirements The service has consulted with CALD consumers in the development of programs Taken satisfaction survey of CALD clients The service has an organisational culture which promotes research and development to trans-cultural health Linked with external agencies that have research focus on health of CALD communities Patient admission forms collect data compatible with the definition of CALD An annually updated profile of CALD communities within its service region Conducted research in collaboration or independently to measure the needs of CALD population in its region The service has budgetary policies that allocate resources and fiscal supports to achieve organisational cultural competence

While these indicators are useful, they are not detailed enough to measure outcomes. Rather they can lead to broad statements of progress without sufficiently quantifying it. This area has been identified as a gap in the literature by many (National Quality Forum, Brach and Fraser, 2002). A search of the literature did not reveal any benchmarks, which is not surprising given the diversity of health care delivery contexts. Kumas Tan et al (2007) identified 54 different instruments designed to measure cultural competence, (a list of some of the key ones is provided in Appendix 5). The authors noted that many of the tools were related to cultural competence linked with individual awareness, knowledge or individual failing. They concluded that measurement tools are highly problematic due to definitions of what constitutes cultural competence, difficulties with assessing power relations and structural inequality and the assumption that developing awareness and knowledge around cultural competence are sufficient to change behaviour. The success of any indicator is based on a number of factors including:


• • • • • • • •

Data and information collected Systems of data collection established Specificity of measures used Time frames in which the monitoring takes place Involvement of stakeholders in the evaluation process Reliability and rigour of processes Reporting systems (Beneforti and Cunningham, 2002; OECD, 1976) Planning or project establishment (at the outset) linkages to the program reporting (after or during implementation)

The Third National Conference on Quality Health Care for Culturally Diverse Populations: Advancing Effective Health Care through Systems Development, Data, and Measurement (2002) noted that assessment, measurement, and data collection was an important but under-developed area of work. They pointed out that funders and consumers want more detailed information about the quality and impact of cultural competence programs, yet the task remains difficult due to the scarcity of appropriate tools and resources as well as reluctance on the part of some providers and health care organisations to participate in evaluation and data collection activities. The challenges identified in developing appropriate measurement indicators were identifies as: Finding the balance between the fluid and dynamic nature of culture and cultural competence and the concrete demands of measurement: • • • • • Managing the complexity that stems from multiple levels of analysis. Balancing short-term versus longitudinal measurement. Compensating for the frequent lack of baseline data, and minimizing the burden of subsequent data collection. Accurately weighing the impact of cultural competence interventions against other factors. Impressing on organisations the value of measurement, and securing the tools, resources and expertise to conduct it. ( - 03a)

It was also noted that a tension often arises between the goals of program evaluation and the desire to produce outcomes data. Programs implementing cultural competence interventions are often under pressure to demonstrate the impact of interventions on different health measures when they are still struggling to understand how best to run their programs and collect basic data on outputs. Given the difficulty of performance measurement, cultural audits have also been put forward as a way to measure progress. Inglehart and Quiney (1997) document an attempt to conduct cultural audits within a school of dentistry. They conclude that: …Conducting a cultural audit is difficult work, often discouraging and frustrating, but always interesting and personally challenging. It must become an ongoing effort for every organisational unit that prepares providers for their professional lives in the next century of this country. Finally, the value of indicators has been questioned and a model of organisational transformation has been put forward as an alternative by Dreachslin (1999:427). He states:


' The notion of organisational change management is noted above in the models of cultural competence.. no checklist of concrete behaviorally-based performance indicators can ever fully capture the essence of diversity leadership.'.Diversity leadership entails re-visioning differences…consequently.. 57 .

risk management. service delivery. Equitable utilisation of health services. consumer engagement. bilingual staff. quality assurance. clinical communication competence with CALD consumers. cultural competence embedded. Therefore some indicators of the process can be less fixed or more qualitative in nature. Integrated data collection systems which can provide cultural data as a sub-set of the whole for example. strategic plans. Consumer participation: in a range of committees. sponsored by the European Commission. Communication: language services. Processes: Streamlined processes. multilingual material. not just cultural diversity committee. implemented in a way that is integrally embedded in the other processes of the organisation. Cultural competence needs to be viewed at different levels on the continuum of individual to systemic. Leadership. cultural competence training. DG Health and Consumer Protection (SANCO) brought together hospitals from 12 member states of the European Union. which often misses the process.10. The domains of assessment and reporting are important. Care delivery and patient support: patient-centred care. Often the measurement is about looking at outcomes at the end.with relevant stakeholders Cultural resources and expertise. Appropriate research which feeds into quality improvement. Workforce diversity and training: for example. Cultural competence is both a process (means) and an end. Removal of disparities in health outcomes. Models of cultural competence need to be adopted. bilingual staff. Clinical processes and procedures: reviewed through cultural diversity lens. a scientific institution as coordinator. formal certificates in cultural competence. TOWARDS A FRAMEWORK OF CULTURAL COMPETENCE ASSESSMENT This literature review indicates there is ample work on models of cultural competence and tools of assessment. and Accountability public reporting of cultural diversity issues in reports. international organisations and networks. consumer participation in quality assurance processes and reporting. use of interpreters. Partnerships and community engagement. GOOD PRACTICE EXAMPLE The European project ‘Migrant-friendly hospitals’ (MFH). culturally competent health care and health 58 . Attitudinal change and non-discrimination. CALD patient satisfaction. These partners agreed to put migrant-friendly. Corporate Systems: policies. experts. The key headings emerging from the literature that are very important are: • • • • • • • • • • • • • • • • • Access to services.

Building awareness of migrant population experiences and existing health disparities and inequities. A Migrant Friendly Quality Questionnaire (MFQQ) tool was developed and 59 . Developing partnerships with local community organisations and advocacy groups who are knowledgeable about migrant and minority ethnic group issues is an important step that can facilitate the development of a more culturally and linguistically appropriate service delivery system. Ensuring that users (actual and potential patients. including those that are gender-related. and organisational regulations). health science disciplines can make important contributions. To test the feasibility of becoming a migrant-friendly and culturally competent organisation the project implemented and evaluated three selected subprojects in European hospitals and professional organisations to acknowledge that the issues are relevant and being prepared to invest in achieving competence. socio-behavioural. Getting staff in health professions. rather than generic criteria they note that. Health sciences through moving diversity issues in health and health care higher up on their agendas. by including them in their theory-building and the development of systematic evidence. There was a pilot program undertaken with 12 hospitals across Europe which began in 2002. Focusing on ethno-cultural diversity implies the risk of stereotyping—but migrant status. Ensuring that hospital owners and management put quality of services for migrants and ethnic minorities on the organisational agenda. (http://www. and the European benchmarking process was resourced by the project. cultural background and religious affiliation are just a few of the many dimensions of the complexity of human beings. In 2004 recommendations were launched as the ‘Amsterdam Declaration towards Migrant Friendly Hospitals in an ethno-culturally diverse Europe. The declaration identified a number of areas which hospitals needed to focus on in making their organisations ‘migrant friendly’ which included: • • • • Developing a migrant-friendly hospital is an investment in more individualised and more person-oriented services for all patients and clients as well as their families.mfh-eu.mfh-eu. representatives of community groups. Local implementation was financed out of hospital funds. Health policy and administration to provide a framework to make migrant-friendly quality development relevant and feasible for each hospital (legal. each service needs ‘to find consensus on criteria for migrantfriendliness/cultural competence/ diversity competence adapted to their specific situation and to integrate them into professional standards and enforce that they are realised in everyday practice’ (Amsterdam Declaration. leading to changes in communication. financial.promotion higher on the European health policy agenda and to support other hospitals by compiling practical knowledge and • • • • • An important recommendation from this Declaration is the need to define what cultural competence means. However. ethnic descent. relatives). patient organisations and community groups put diversity and health and health care on their respective agendas. http://www. Ethnic and migrant background information should be included as a relevant category in epidemiological. health service and health system research. organisational routines and resource allocations. as a first step. clinical.

An initial assessment in 2003 showed a heterogeneous European hospital group.implemented across the 12 hospitals to assess how friendly hospitals were to immigrants. 2004. Dec 9-11. a search of the conference proceedings did not yield sufficient detail of the evaluation of the project. A major strategy to test the feasibility of becoming a migrant-friendly and culturally competent organisation was the implementation and evaluation of evidence and experience-based interventions in these three specific areas. with some hospitals listing.pdf). cultural barriers/lack of cultural competencies. 60 . family visits. information material for migrant patients. Three project areas were selected to be worked upon: • • • Improving interpreting services Migrant-friendly information and training for mother and child care Staff training towards cultural competence. many existing migrant-friendly services and a well-established management structure in place. The results after one year of work within the European project showed that the majority of hospitals could use the project for considerable improvements both on the level of services as well as for developing their quality management systems (http://www. While the project summary states that experiences and results were presented at the Final Conference ‘Hospitals in a Culturally Diverse Europe’ in Amsterdam. lack of culturally appropriate food and spirituality and social support. culturally sensitive services (religion. culturally appropriate patient information and education.mfh-eu. food).net/public/files/mfh-summary. The six problem areas were identified as: language and communication. but with other hospitals showing considerable areas for further development. The MFQQ proved useful in systematically assessing migrant-friendly structures such as interpreting services. as well as components of a (quality) management system to enable and assure the migrant-friendliness of services.

Applying existing tools and initiatives to create cultural competence for example. Ensuring performance against these mechanisms. Strategies therefore targeted to individuals are more likely to be effective when they are implemented alongside those aimed at building community. and Appropriate resources for cultural competence initiatives. and Measures to build a culturally competent workforce. Leadership for organisational change to implement cultural competence. continuous improvement cycles. triple bottom line reporting. NHMRC (2005) points out mandatory measures need to be supported by initiatives that promote good governance and reward change. medium and long-term goals and use business best-practice tools to achieve sustained cultural responsiveness. safety and quality initiatives. education and capacity building. quality of care. However cultural competence practice in health settings is problematic and implementation and reporting are fragmented. standards and accreditation. This can be further supported by developing culturally sensitive practice such as that being undertaken in the Migrant Friendly Hospital project or in the United States to measure CLAS outcomes. Streamlining reporting processes. risk management and safety systems. It has been noted in this document that addressing discrimination at the personal level is not straight forward as it often reflects broader community and organisational norms. set achievable short. From this literature review it is noted that there are significant challenges in the implementation and reporting of cultural competence. planning. Health organisations. An approach that combines mandatory measures with incentives for improvement includes: • • • • • • • Strong accountability mechanisms. policy makers and planners need to seek data. Systematic change management strategies. and evaluation. develop infrastructure. Creating cultural competence requires a shift in thinking as well as practice. Integration of cultural competence initiatives with allied health practices such as quality improvement. These include: • • • • • • • Precise definitions of what is meant by cultural competence. Future directions in 61 . organisational and societal environments that promote and respect diversity. risk assessment/management. An evidence base built on culturally competent research that can inform policy. Persuasive leadership for change at senior levels across the sector. Context specific benchmarks and indicators.11. CONCLUSION It is evident from this review that in Australia much has been achieved at the Commonwealth and state levels in terms of recognition of the challenges faced by culturally and linguistically diverse populations and health services. Appropriate consumer participation.

62 .the work relating to cultural competence must pay attention to the lack of consistent definition and framework. strategies to making it integral to the operation of the agency and appropriate measurement indicators of progress.

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71 .RESOURCES Appendix 1 Minimum Reporting Requirements Under HSCDP The six areas detailed in the HSCDP are: Understanding clients and their needs Data: Accurately gathering a range of information pertinent to the CALD client group will better assist your service to effectively respond to their needs through strategic and targeted planning. strategies and service delivery? Partnerships with multicultural and ethno-specific agencies Knowledge: Working in partnership with ethno-specific and multicultural organisations can assist your health agency to develop a better understanding of the dynamics of the CALD community in your area. • Are there organisational policies on when to use language services? • Are there organisational procedures on accessing language services? • Does the current range of translations reflect community language groups? • Is the organisational information available in plain English? Encouraging participation in decision-making Engagement: Encouraging individuals and organisations to formally take part in the health service’s decision-making process will lead to better service and planning outcomes for your health service and CALD clients. • Do recruitment methods include strategies to reach out to local communities? • Does the human resources department have a system to report diversity awareness progress to the board? Using languages to best effect Language: The effective management. and result in better service delivery outcomes for your health service and CALD client group. provision and reporting of interpreting and translating services is vital to improve access and communication to services for persons with low proficiency in English. and result in a more culturally responsive workforce. • Does current data collection adequately map the CALD client profile? • Does current data inform the development of policy. • What initiatives could benefit from a partnership with local CALD communities? • Are the community groups and agencies the health service works with reflective of the diverse groups in and around the health organisation? A culturally diverse workforce Skills: Employing staff with a range of culturally appropriate competencies will better equip your service to respond to CALD issues and clients.

and visible to staff and the public? Source: of which the CALD clients group is an integral part.pdf 72 .• • • • Does the organisation consider CALD representation in the formation of its committees and working groups? Promoting the benefits of a Victoria Education: Promoting diversity and its benefits will result in a more responsive workforce and lead to increased health benefits for the community. Is diversity awareness and cultural competence training required for all leadership positions and staff? Is the organisational diversity reflected in the mission and values

Source: 73 .vic. Mental health involvement and representation in government initiatives to improve the wellbeing of culturally and linguistically diverse communities and address barriers to appropriate use of mental health 2 Core Strategies of the Cultural diversity plan for Victoria’s specialist mental health services 2006–2010 • • • • • • Culturally competent practice within mental health services and recognition of this as a core skill required of staff. Action to address the specific mental health needs of refugees. consumers and carers and to incorporate these perspectives into service and workforce planning. Stronger government mechanisms for monitoring mental health services’ accessibility and responsiveness to culturally and linguistically diverse communities. Action by mental health services to understand the needs of local ethnic communities. Action to address the barriers to the appropriate use of language services (interpreting and translating) in mental health

and promote at all levels of the organisation a diverse staff and leadership that are representative of the demographic characteristics of the service area.Appendix 3 Culturally and Linguistically Appropriate Services and Standards (USA) 1. at no cost to each patient/consumer with limited English proficiency (LEP) at all points of contact. 2. Health care organisations should ensure that data on the individual patient's/consumer's race. Health care organisations must make available easily understood patient related materials and signposting in the languages of the commonly encountered groups and/or groups represented in the service area. Health care organisations should maintain a current demographic. 5. 4. Health care organisations should conduct initial and ongoing organisational selfassessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits. Family and friends should not be used to provide interpreting services (except on request by the patient/ consumer). Health care organisations must offer and provide language assistance services. and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area. 8. retain. Health care organisations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying. 9. and periodically updated. including bilingual staff and interpreter services. and promote a written strategic plan that outlines clear goals. and outcomes-based evaluations. 10. collaborative partnerships with communities and utilise a variety of formal and informal mechanisms to facilitate community and patient/ consumer involvement in designing and implementing CLAS-related activities. and spoken and written language are collected in health records. understandable. Health care organisations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. Health care organisations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. Health care organisations should develop participatory. 12. 7. policies. Health care organisations should implement strategies to recruit. Health care organisations should develop. and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. ethnicity. operational plans. 6. patient satisfaction assessments. 11. 3. and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services. cultural. in a timely manner during all hours of operation. Health care organisations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. integrated into the organisation's management information systems. 74 . performance improvement programs. implement. 13. Health care organisations should ensure that patients/consumers receive from all staff members effective.

Health care organisations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information 75 . 14. and resolving cross-cultural conflicts or complaints by patients/consumers.preventing.

Communication: The exchange of information between the organisation/providers and the clients/population. Planning Monitoring and Evaluation: The mechanisms and processes used for: • Long and Short-term Policy. Organisational Infrastructure: The organisational resources required to deliver or facilitate delivery of culturally competent services: • Financial/Budgetary • Staffing • Technology • Physical Facility/Environment • Linkages. Programmatic. and other organisational vehicles to help ensure the delivery of culturally competent care: • Community Involvement and Accountability • Board Development • Policies.Appendix 4 Lewin Group Cultural Competence Domains (2002) Organisational Values: An organisation’s perspective and attitudes regarding the worth and importance of cultural competence. policy-making. Investment and Documentation • Information/Data Relevant to Cultural Competence • Organisational Flexibility. Governance: The goal setting. Staff Development: An organisation’s efforts to ensure staff and other service providers have the requisite attitudes. and its commitment to providing culturally competent care pertaining to: • Leadership. and internally among staff. and Operational Cultural Competence Planning Informed by External and Internal consumers • The Systems and Activities Required to Proactively Track and Assess Organisational Cultural Competence • Client. 76 . • Understanding of Different Communication Needs and Styles of Client Population • Culturally Competent Oral Communication • Culturally Competent Written/Other Communication • Communication with Community • Intra-Organisational Communication. Community and Staff Input • Plans and Implementation • Collection and Use of Cultural Competence-Related Information/Data. knowledge and skills for delivering culturally competent services: • Training Commitment • Training Content • Staff Performance indicators. in ways that promote cultural competence.

and health related services in a culturally competent manner: • Client/Family/Community Input • Screening/Assessment/Care Planning • Treatment/Follow-up.Services and Interventions: An organisation’s delivery or facilitation of clinical. public health. 77 .

M. Roszkowski. Vito. 131-140.htm ■ Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised (IAPCC-R©) – Developed by Campinha-Bacote (2002). Reliability testing revealed a Cronbach's alpha of . School of Nursing. Mason and Ward. Fitzgerald. and cultural skill and cultural encounters).lsu. This tool has also been translated into several languages and used internationally. disagree. cultural encounters. G. Burnett. the IAPCC-SV© is based on the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised (IAPCC-R©).72-0. strongly disagree and modifying and deleting selected questions on the IAPCC-R©. to measure student reports of components of content on cultural competence taught in undergraduate and graduate nursing programs. ‘Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised’ in which they administered the IAPCC-SV© to 91undergraduate nursing students at Bellarmine University Lansing School of Nursing and Health Sciences to establish reliability of this tool. cultural awareness.783. ■ Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Version (IAPCC-SV©) – Developed by Campinha-Bacote (2007). Psychometric Testing of a Proposed Student Version of the Tool. as well as items adapted from Campinha-Bacote's tool (IAPCC-R). ■ Cultural Diversity Questionnaire For Nurse Educators – Developed by Lorinda Sealey (2003).pdf ■ Blueprint for Integration of Cultural Competence in the Curriculum Questionnaire (BICCCQ) –The 31-item BICCCQ was developed at the University of Pennsylvania. The Cultural Diversity Questionnaire For Nurse Educators is based on Campinha-Bacote's model of cultural competence and includes items related to cultural awareness. cultural knowledge. Studies were conducted with a variety of healthcare professionals and reliability scores ranged from a Cronbach's alpha of 0. The Process of Cultural Competence in the Delivery of Healthcare Services (1998) and measures the five constructs of this model (cultural desire. Research on the tool is published in the following citation: Sealey. cultural skill. The IAPCC-SV© is a result of modifying the response format of the IAPCC-R© to reflect only responses of strongly agree. cultural knowledge. (2006). Contact: lsealey@selu. Click onto the following link for more details of this tool. Cronin and CampinhaBacote (2007) conducted a study entitled. This tool also consists of items adapted from research conducted by Goode.Appendix 5 Cultural Competence Assessment Tools Source: http://www. L. this fifty-five item tool includes statements developed by this researcher. and cultural desire. the IAPCC-R is based on her model of cultural competence. and Wieland (2005) noted in a study of 695 student nurses that the IAPCC-SV© could be further revised resulting in a higher reliability of this tool. 13(1).edu/docs/available/etd-1112103-133929/unrestricted/Sealey_dis. BICCCQ items 78 . Cultural Competence of Baccalaureate Nursing Faculty: Are We Up to the Task? Journal of Cultural Diversity. http://etd. Click onto the following link for more details of studies using this tool.90..

Citation: Tulman. (2008). R. and Hood. Journal of Nursing Measurement 11(1):29-40. Transcultural Nursing Practice Described by Registered Nurses and Baccalaureate Nursing Students.. A. Ludwig Beymer. P. L. discussion 266-267. 79 . It is a five-point likert-type scale which measures a student's ability to make culturally sensitive choices. Research on the tool is published in the following citation: Schim. E. Development of a Cultural Competence Assessment instrument. The Office of Minority Health and the Joint Commission have each developed standards for measuring the cultural competence of organisations.. the ITCCRS was created to assess 109 child care providers' cultural competence and the demographic correlates of that competence. The ITCCRS consists of 40-items. R. Journal of Research in Childhood Education. ■ Cultural competence Organisational Assessment – 360 (COA360) – The COA360 is an instrument designed to appraise a healthcare organisation's cultural competence. Subjects were from 30 randomly selected infant/toddler centers that were licensed to provide child care. 9: 1525. and 11 measuring skills. and Watts. Cronbach's alpha ranged from . which is designed to measure cultural diversity experience. which was developed to measure faculty report of components of content on cultural competence in medical school curricula.94 across factors and was . 19(3). Journal of Transcultural Nursing. K. 24(3). (2003). ■ Cultural Competence Assessment (CCA) – Schim and colleagues developed the CCA instrument. ■ Transcultural and International Nursing Knowledge Inventory (TINKI) – Baldonado et al (1998) developed the TINKI. Journal of Professional Nursing. and Sawaya. Relosa. ■ Cross-Cultural Evaluation Tool – The Cross-Cultural Evaluation Tool was developed by Freeman.. Citation: LaVeist. and competence behaviors among health services and staff. Citation: Hughes.. S. Development and testing of the Blueprint for Integration of Cultural Competence in the Curriculum Questionnaire. and Anonas-Ternate A. (2008). Obegi. (2007). 161-166. Barnes. S. N. R.Based on Sue's (1981) tri-dimensional model.were derived from the Tool for Assessing Cultural Competence Training. (2005).. Journal of Healthcare Management. A. 53(4):257-66. which is a questionnaire that includes closed and open-ended questions related to participant's experiences in providing cultural care. ■ Infant/Toddler Caregiver Cultural Rating Scale (ITCCRS) . 19 measuring knowledge. 10 items assessing awareness. L. Nemivant. 18:57-62.. D.. Hughes and Hood (2007) published an article which presents the psychometric properties of the Cross-Cultural Evaluation Tool that yields a cross-cultural interaction score. Journal of Transcultural Nursing. K. Doorenbos. T. Starsiak. Teaching Methods and an Outcome Tool For Measuring Cultural Sensitivity in Undergraduate Nursing Students. 199-213. Miller. and Ritblat. and Benkert.96 overall. The COA360: A Tool for Assessing the Cultural competence of Healthcare Organisations. awareness and sensitivity. The COA360 is designed to assess adherence to both of these sets of standards. J. Citation: Baldonado. Cultural Competence in Infant/Toddler Caregivers: Application of a Tri-Dimensional Model. A.73 to .

E. Mohr. Becker.. J. Sedlacek. The scale's three subscales are diversity of contact.. This scale makes the theoretical leap that tolerance of difference is key to intercultural work and cultural competence... relativistic appreciation. ■ Tucker-Culturally Sensitive Health Care Inventories (T-CSHCI) – Tucker has developed three race/ethnicity-specific forms of the T-CSHCI (one each for African Americans. attitudes and beliefs. and comfort with differences. S. Citation: Fuertes. this 26-item 5-point Likert scale tool measures attitudes toward sociocultural issues in medicine and patient care. J. based on a review of the literature. 249-257. 77(6).. ordered into three subscales: (1) Cognitive (knowledge. 42 (6). The TSET consists of 83 items.. Measurement and Evaluation in Counselling and Development. H. consisting of 25 items). Becker. 33..Developed by Tang et al. Cookston. consisting of 28 items). Implementation and Evaluation of an Undergraduate Sociocultural Medicine Program. 80 . According to the tool’s authors. and Gretchen. J. (2) Practical (interview. Bozynski..578-585. Hispanics and non-Hispanic whites) to be used by patients at communitybased primary care centers to evaluate the level of patient-centered cultural sensitivity perceived in the health care that they experience. D. M. L. and Gretchen. W. 2000). B. M. and developed scale items in each of these categories: (1) general educational experience. ■ Transcultural Self-Efficacy Tool (TSET) – Developed by Jeffreys (2000). Miville. Miville. and (5) patient care/clinical issues. and (3) Affective (Values. J. N. Measuring Cultural Awareness in Nursing Students. Academic Medicine. 157-169. conceptually based on the literature of transcultural nursing. Khosropour. ■ Tailoring Initiatives to Meet the Needs of Diverse Populations: A Self-Assessment Tool – A self-assessment tool is provided in Chapter 8 of One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations to help organisations evaluate the way they currently provide care and services to diverse patient populations. ■ Sociocultural Attitudes in Medicine Inventory (SAMI) . (2002). which emphasizes an ability to tolerate similarities and differences between one's self and another. Journal of Nursing Education. (2003). and Martinez. transcultural self-efficacy refers to perceived confidence in performing or learning transcultural skills. Sedlaki. (4) behaviours/comfort with interactions. b) assess specific provider and office staff behaviours and attitudes and healthcare center policies and physical characteristics. this tool is designed to measure the degree of cultural self-efficacy among nursing students. Rew. The authors identified five key categories of cultural awareness. The questions are designed to promote discussion around the need to improve or expand current initiatives to meet patients’ cultural and language (CandL) needs. J. T. S.. The T-CSHCI Patient Form: a) are for patient use by patients. This scale is based on the theoretical model called the UniversalDiverse Orientation (Fuertes. ■ Cultural Awareness Scale (CAS) – Developed by Rew. L. (3) research issues. Tang.■ Miville-Guzman Universality-Diversity Scale (M-GUDS) – This is a 45-item questionnaire rated on a 6-point Likert-type scale ranging from strongly agree to strongly disagree.. Factor structure and short form of the Miville-Guzman Universality-Diversity Scale. and Martinez (2003) to measure the multidimensional nature of cultural awareness in nursing students. (2) cognitive awareness. Mohr. Khosropour. consisting of 30 items). and Adams. Fantone. (2000). Cookston.

Curry. The project included an interdisciplinary model for teaching pre-health undergraduate students (premedicine. and one open-ended clinical case vignette question. and programs. Christopher Wong is director of physical therapy programs at Touro College.psych. Assessments for Measuring PatientCentered Cultural Sensitivity in Community-Based Primary Care files/Piontek_Mary_203. 27 West 23rd Street. Citation: Hammer. (Intercultural Press and personal autonomy.1-800-370-2665). Rooks.. New York.htm ■ Competence Continuum (CCC) – Based on Cross's (1989) Cultural Competence Continuum Model of the 6 stages of cultural competence along a continuum. This behavioural assessment of cultural competence may provide a method for providing feedback aimed at professional development in the area of cultural competence for students. Ferdinand.. R.c) emphasize assessment of cultural-specific interpersonal behaviours.. L. A. R. 609-619. M. For more information contact Dr. perceptual acuity. NY 10010 ( or visit http://c2003. and Wiseman. Piontek at mpiontek@umich. Measuring intercultural competence: The Intercultural Development Inventory. decide whether to work in a culturally diverse company and whether to live abroad. R. and d) consist of items generated by low-income racial/ethnic minority and majority patients. J. http://www. she has also developed the T-CSHCI Provider Form and the T-CSHCI Staff Form.ufl. flexibility and openness. Health. become self-aware. Jones. and ethnicity. faculty. (2003). L. ■ Intercultural Development Inventory (IDI) – The IDI was designed by Bennett and Hammer and measures how a person or a group of people tend to think and feel about cultural difference. Journal of the National Medical Association. pre-nursing. The aim of this grant was to rethink ways cultural diversity is taught in pre-health education. Carolyn Tucker's home page at: http://www. and to prepare to enter another culture. and Medicine. Walker..doc 81 .org/images/uploads/Publications/OC609.. The CCAI measures the 4 variables of emotional resistance. J. ■ Cultural Bases of Health Survey (CBHS) – The CBHS instrument consists of three close-ended and one open-ended demographic questions. Based on Tucker's Patient-Center Culturally Sensitive (PC-CS) Health Care Model. (2007). M. Bennett. ■ Cross-Cultural Adaptability Inventory (CCAI) – Developed by Kelly and Meyers (1993) to help participants understand the qualities that enhance cross-cultural %20about. Beato. Wong converted this conceptual model (CCC) to an ordinal scale to assess behavior in cultural interactions revealed in reflective student writing.. This instrument is a result of the’ Seeing the Body Elsewise: Connecting the Pre-Health Sciences and the Humanities grant project of the University of Michigan's Program in Culture.nmanet. T. Likertscale cultural competence questions. Citation: Tucker. 99(6). gender. ppp.. International Journal of Intercultural Relations. 27(4). Please visit Dr.421-443. C.. The IDI is based on Bennett’s Developmental Model of Intercultural Sensitivity. 35 close-ended.evaluationcanada. Mirsu-Paun.B. clinicians. health. This tool s based on the premise that students' reflective writing can be analysed using the CCC to reliably and objectively assess the degree of cultural competence revealed in specific cultural interactions.pdf. J. van der Berg. pre-life sciences) about the intersections of race.. The CBHS is one of the project’s evaluation activities.

and 4) the patient/enrollee-provider encounter. Tools for Assessing Cultural Competence.msh. 3) inter-staff relationships at all levels. attentive. This website also has a section devoted to other tools that assess institutional and organisational cultural competence. The BEVI asks ‘extensive background and demographic items along with validity and process scales in order to assess variables that may influence or shape both the processes and outcomes of international or multicultural learning.pdf ■ Measures of Cultural Competence .doc. Events. I n Appendix C-1 there is a chart entitled Measures of Cultural Competence (page 83 ) that lists cultural assessment tools for healthcare professionals. and self / emotional and 2) whether an individual references decisions internally based on existing knowledge and values or externally. http://thinkculturalhealth. It measures two orientations related to the psychological stresses associated with dealing with new cultural environments: 1) an individual ‘s orientation towards change vs. Cultural competence and Nursing: A Review of Current Laura Avakian and Yoku Shaw-Taylor.umich. Thomas Delbanco.Program For Multicultural Health has a website that contains a web page entitled. based on the knowledge and values of others. This report can be accessed at: 82 . This webpage can be accessed at: These two measurements are combined to produce four dimensions that represent different intercultural learning orientations: proactive.The American Institutes of Research prepared a report for the Office of Minority Heath US Department of Health and Human Resources entitled. stability.■ Beliefs. pdf ■ Tools for Assessing Cultural Competence . and adaptive. http://erc. Dr.umich. Policies and tendency to stereotype. to conduct organisational assessments of their cultural competence. 2) the administration and management's relationship with staff. The Personal Intercultural Change Orientation (PICO) instrument was developed. http://www. Gilbert (2003) provides a list of organisational and healthcare professional cultural assessment tools.aspx?l=2 ■ Cultural Competence Self Assessment Protocol for Health Care Organisations and Systems – Developed by Dennis Andrulis. protective. including hospitals and clinics. receptivity to different cultures.pico-global. The protocol’s questions are organized according to the following four cornerstones of cultural competence:1) health care organisation's relationship with its community. and Values Inventory (BEVI) – The BEVI is a 494-item instrument that is designed to evaluate basic openness. This webpage can be accessed at: http://www.htm#HPA ■ Resources in Cultural Competence Education For Health Care Professionals – In this California Endowment publication (pages 38-46).’ ■ Personal Intercultural Change Orientation (PICO) – Based on the Deep Culture model of intercultural learning by this tool can be used by health services.

(2008).hogg.pdf It is designed to examine all components of a curriculum.Hogg Foundation For Mental Health has complied a resource list entitled Cultural Competence Tools. G. http://www. ■ Patient Report Measure of Provider Cultural competence – Authors Tools and Resources – Janet Rhymes and Darren Brown published a report entitled. Falzarano. o Client Tools to assess clients' experience of the organisation and/or clinician’s cultural competence.http://www.html 83 . http://www.pd f. 185-193. S. awareness. Menon and Cunningham developed a theoretically grounded and patient report measure of provider cultural competence. Menon..’ describes the tool and its use.aamc. and mpetence. o Provider Tools to assess clinicians' cultural competence in working with clients. Ella Cleveland at ecleveland@aamc. 27(2).aamc. It includes specific domains and components and can be viewed at: http://www.cdha.xls.utexas. where gaps in the curriculum exist.. P. the Tool for Assessing Cultural Competence Training (TACCT) is a self-administered assessment tool with broad applicability to other health professions disciplines. T. Citation: Lucas..calendow. This tool is based on a study of predominantly African American patients (N = 310) who were recruited from three urban medical clinics to complete a survey about their relationship with their physician. and skill. The or (202) 828-0531. W. Healthcare Provider Cultural competence: Development and Initial Validation of a Patient Report Measure. Psychometric analyses supported a tripartite model of cultural competence that was comprised of patient judgments of their physician's cultural knowledge. This report provides a brief overview of the concept of cultural competence with an emphasis on useful tools and resources.pdf ■ Tool for Assessing Cultural Competence Training (TACCT) – Developed by the Association of American Medical Colleges (AAMC ) to help medical schools assess cultural competence training. ‘Cultural Competence Education for Medical Students: Assessing and Revising educational elements that have been previously unrecognised. This resource list includes some examples of the following types of cultural competence tools: o Organisational Tools to assess their organisation’s level of cultural competence at an administrative level. Health Psychology. and planned and unplanned redundancies. This article can be accessed at This report can be accessed at: http://www. ■ Cultural Competence Tools . Michalopoulou. Falzarano. including the following areas: where culturally competent care is currently taught. Tools and Resources.pdf ■ Summary Report Cultural Competence in Primary Health Care: Perspectives. For more information about the tool contact Dr. Summary Report Cultural Competence in Primary Health Care: Perspectives.

pdf ■ Cultural competence Challenge – The American Academy of Orthopaedic Surgeons (AAOS) has developed the Cultural competence Challenge to assist in learning or reinforcing one’s individual knowledge of cultural care issues. HRSA's Office of Minority Health and Office of Planning and Evaluation provided both oversight and substantive input to the ■ Colour-Blind Racial Attitude Scale (CoBRAS) – The CoBRAS is a 20-item self-report measure. revised 2002).htm#Assessing ■ Cultural Self-Assessment Resources and Tools for Self-Assessment of Cultural and Linguistic Competence – The National Center For Cultural Competence in Health Care (NCCC) has developed the webpage Curricula Enhancement Module Series. the scale ranges 84 .1989. PhD. Inc. Contact Dr. and serves as a future building block that advances the conceptualization and practical understanding of how to assess cultural competence at the organisational level.’ http://www. the Cultural Competence Assessment Tool (CCAT) guides healthcare organisations through an examination of the administrative structures and practices described in the CLAS It is stated to be particularly useful in a residency setting to teach the next generation of orthopaedists. such as the National Standards for Culturally and Linguistically Appropriate Services (CLAS).Sponsored by Blue Cross Blue Shield of Massachusetts Foundation. http://www. This project is aimed to contribute to the methodology and state-of-the-art of cultural competence assessment.■ Cultural Competence Assessment Tool (CCAT) .net. that contains ‘Cultural Self-Assessment Resources’ and ‘Tools for Self-Assessment of Cultural and Linguistic Competence. Denise Dodd. T.bphc. Participants respond utilizing a 6-point Likert-type scale. without the pressure of an actual patient encounter. The CD-ROM program was showcased at their 2005 AAOS Annual Meeting and is offered via the AAOS Diversity in Orthopaedics Web site: http://www.hrsa.An Organisational Cultural Competence Assessment Profile .pdf ■ Cultural Sensitivity Service Directory Self-Assessment – This tool was developed to heighten awareness of how one views clients from culturally and linguistically diverse populations (Goode.aaos. developed this tool with input from staff at the Boston Public Health Commission. D. http://www. The product .info/resources_mod2. Ramon at ramon@jimenez.pdf ■ Organisational Cultural Competence Assessment Profile – The Health Resources and Services Administration (HRSA) sponsored a project to develop indicators of cultural competence in healthcare delivery organisations.asha. http://www.asha.builds upon previous work in the field. T. revised 2002).html#appendixa ■ Cultural Sensitivity Personal Reflection Self-Assessment – This tool was developed to heighten awareness of how one views clients from culturally and linguistically diverse populations (Goode. The project was implemented through a contract with The Lewin Group.nccccurricula.

’ This section provides information on over 10 cultural assessment tools. Total score which encompasses all three subscales can range from 20 to 120 with higher scores representing more colour-blind racial attitudes. They are seeking collaborations with communities or organisations that are interested in using the instrument and that are willing to share data so psychometric properties of the scale can be further investigated. R. The purpose of this report was to identify and review the most relevant assessment tools for the set of organisational cultural competence standards and to make recommendations regarding the future evaluation of organisational cultural competence http://www. The CCCI is administered via a structured interview.from 1 (strongly disagree) to 6 (strongly agree). and a review of relevant research literature. H.asp. For more 85 . UMDNJ-Robert Wood Johnson Medical School has developed the Clinical Cultural competence Questionnaire (CCCQ) for assessing physicians' knowledge.pdf ■ Clinical Cultural competence Training Questionnaire (CCCTQ) – Developed by Krajic. ■ Clinical Cultural competence Questionnaire (CCCQ) – The Center for Healthy Families and Cultural Diversity. and agency services and structure. Lilly. and Unawareness of Blatant Racial Issues. and attitudes relating to the provision of culturally competent health care to diverse patient populations. Organisational Cultural Competence: Self-Assessment Tools For Community Health and Social Service and Pelikan. http://www.mfh-eu.uottawa. community and family involvement. Journal of Counselling Psychology. interviews. This European Union Migrant Friendly Hospitals initiative tool is translated into seven languages.htm ■ The Client Cultural competence Inventory (CCCI) – The CCCI was developed through a process that incorporated information from focus groups with providers and 21-12-2005. R. Citation: Neville. Department of Family Medicine.. Trummer. Results gave evidence of the tool’s usefulness both in assessing cultural competence directly and in providing valuable informational input into a larger process of planning for continuous quality improvement. and Browne. Unawareness of Institutional Discrimination. The research team continues gathering data and refining the CCCI. In the field test family members were asked to rate service coordinators by responding to items grouped into four subscales: respect for cultural differences. Lee. The three subscales which comprise the CoBRAS are Unawareness of Racial Privilege. G.htm. ■ Organisational Cultural Competence: Self-Assessment Tools For Community Health and Social Service Organisations – The Centre for Research on Community Services of Centretown Community Health Center at the University of Ottawa produced a report entitled. Duran. skills. M. L. L. Schulze. 47.etsu..socialsciences. Strabmayer. A. Construction and initial validation of the Color-Blind Racial Attitudes Scale (CoBRAS). (2000).umdnj. ■ Eastern State University's Office of Cultural Affair – Eastern State University's Office of Cultural Affair has a comprehensive website on cultural resources that contains a section on ‘Evaluation. the Clinical Cultural competence Training Questionnaire (CCCTQ) is an adapted version of the CCCQ for a hospital setting. http://www. appropriateness of assessment and treatment options. 59-70. Like.

Curriculum and Culture (C3) Instrument – Developed by Haidet. Palacio. 2007. Characterizing the Patient-Centeredness of Hidden Curricula in Medical Schools: Development and Validation of a New Measure.sietar. Journal of Public Health Medicine.. Jenckes. A. E. L. (2004). 26(4):388-396. (2007). and Feuerstein.and fourth-year students at ten medical schools in the United States. 80(1). C. contact Sara Hudson Teaching and Learning in Medicine. and Chou. 19(2). A. K.... 86 . the purpose of this instrument is to help educators characterize and understand the hidden curriculum at their own institutions. ■ SIETAR-Europa – The website. http://www.%20ICC%20Assessment %20Tools_87-94_... SIETAR-Europa. Beach. Adam. Based on Low. Citation: Gozu. is a 55-item questionnaire measuring medical students' background. and Chou. E. The authors developed survey items to measure three content areas of the hidden curriculum with respect to patient-centered care. 180190. and perceived support for students' own patientcentered behaviors. and Low. Assistant Professor of Psychiatry at the University of Pittsburgh at (412) 624-1703 or scholles@pitt. ■ The Slope Index of Inequality (SII) – A spreadsheet tool designed to help the user calculate socioeconomic inequalities in health within an area using small area health measures..information.D. A. Cooper. T.. Measuring the Gap: Quantifying and Comparing Local Health Inequalities. 44-50. ■ Cross-Cultural Diversity Experiences and Attitudes Questionnaire – Developed by Guiton et al. They concluded that most studies of cultural competence training used self-administered tools that have not been validated. Academic Medicine. Adam. They included 45 articles in their review comprising a total of 45 unique instruments (32 learner self-assessments.pdf. the authors selected items for the final version of the C3 Instrument. The survey was distributed to third. Citation: Haidet.experiment.. These tools can be found at http://www. N. These content areas include role modelling. students' patient-care experiences. Gary. lists an annotated bibliography of over 50 intercultural assessments and instruments. M.. M. K. C.. Bass. Robinson. 13 written exams) that were used in the 45 articles. Smarth.Gozu (2007) and colleagues systematically reviewed articles published from 1980 through June 2003 that evaluated the effectiveness of cultural competence curricula targeted at health professionals by using at least one self-administered tool. P. ■ Communication. experiences. Using factor analysis. A..html ■ Assessment Tools of Intercultural Communicative Competence – Fantini (2006) developed a list of 87 Assessment Tools of Intercultural Communicative Competence. Powe. (2005). and attitudes related to cross-cultural C. Ph. ■ Self-Administered Instruments to Measure Cultural Competence of Health Professionals: A Systematic Review . Self-Administered Instruments to Measure Cultural Competence of Health Professionals: A Systematic Review.

nursing. M. A. It is based on the Papadopoulos. M. Journal of Social Work Education at: http://www. Tampa. Nesman. 240-2). and Townsend. FL: University of South Florida. Mernandez. ■ CAMHS CCATool – The Children and Adolescent Mental Health Services (CAMHS) Cultural Competence in Action Tool (CCATool) is a tool that measures the cultural competence of individuals working with children and adolescent mental health services. practice. Review of Multidisciplinary Measures of Cultural Competence for Use in Social Work Education.. D.. M. A. http://www.. and structure. They come from various disciplines including social work. Worthington. Citation: Krentzman.iffcmh. Citation: Harper. and Isaacs.. Mowery. (2008). Advances in Contemporary Transcultural Nursing 2nd edition. 87 . and education. (2006). The measure is based on the Child and Adolescent Service System Program Cultural Competence Model.. All were written in the United States except for one developed in the United Kingdom. Cultural Competence in Action for CAMHS: Development of a Cultural Assessment Tool and Training. Papadopoulos. Tilki. Nesman.accessmylibrary. M. This article provides an excellent review of these tools.. the CCSAQ is designed to assist service agencies working with children with disabilities and their families in self-evaluation of their cross-cultural competence. T. medicine.pdf ■ Cultural Competence Self-Assessment Questionnaire (CCSAQ) – Developed by James Mason (1995).org/Assessment%20Protocols. J. allied health sciences. Louis de la Parte Florida Mental Health Institute. S.. and Townsend. ■ Organisational Cultural Competence: A Review of Assessment Protocols – Authored by Harper. The search for assessment tools meeting criteria yielded 45 instruments.. Contemporary Nurse. and Isaacs. (2008) sought measures of cultural competence from as many sources as possible and found a total of 19 measures/instruments that met the inclusion criteria for this analysis. Mowery. college student affairs. T. and Ayling.. FMHI pub. M. M. 129-140. applied health. R. The tools were developed between 1986 and 2005.■ Review of Multidisciplinary Measures of Cultural Competence for Use in Social Work Education – Krentzman. pharmacy. D. J. policy. counselling psychology. Research and Training Center for Children’s Mental Mental Health Assessment Tools ■ Making Children’s Mental Health Successful: Organisational Cultural Competence: A Review of Assessment Protocols –This monograph presents the findings from a review of cultural competence assessment tools designed for the use at the organisational level that focused on health or mental health. no. Worthington. This model describes cultural competence in terms of four dimensions: attitude. The Cultural Competence Self-Assessment Questionnaire (CCSAQ) was designed for use in child and adolescent mental health systems.. A. Tilki and Taylor's model of cultural competence. 28(2). Citation. Organisational cultural competence: A review of assessment protocols. A final selection of 17 organisational assessment instruments was examined in this report. (2008). A. Hernandez. This instrument is intended to help service providers and staff at child and family serving agencies to assess their cross-cultural strengths and weaknesses in order to design specific training activities or interventions that promote greater competence across cultures..

The C-CAT Tool Kit was developed in conjunction with mental health is a guide to planning and implementing cultural competence assessments. and training and promotional materials. a Columbus-based management consulting firm. service planners and providers. cultural competence ■ A Practical Guide for the Assessment of Cultural Competence in Children’s Mental Health Organisations – With support from a federal grant from Child Mental Health Services of the Department of Health and Human Services. racial/ethnic identity.Authored by Zetzer and Shockley (2005). with brief reviews of 14 assessment tools. the Technical Assistance Center of Judge Baker Children’s Center developed a manual with a list of cultural assessment tools. providers.htm ■ The California Brief Multicultural competence Scale (CBMCS) – The CBMCS can be used by an agency to identify the training needs of the agency In addition. and contact information. family members. and the Outcomes Management Group. authored by Dr. which is a set of dynamic measurement instruments that allow systems and organisations to assess their cultural competence from the perspective of an array of raters.p df ■ Build the Field and They Will Come: Multicultural Organisational Development for Mental Health Agencies . resources for post-assessment cultural competence. Awareness of Cultural Barriers: Challenges people of color experience accessing mental health services. is a publication that contributes to understanding how cultural competence is currently operationalised and measured at the organisational level. Pages 8-14 of this document provides readers with an annotated bibliography of several organisational cultural assessment tools.M. This manual. http://www. A Practical Guide for the Assessment of Cultural Competence in Children’s Mental Health Organisations. This monograph compares organisational assessment instruments through the following questions: For what type of organisation was the instrument developed? How were the instruments developed? How do the authors define cultural competence? What domains do the authors use as categories of analysis? http://rtckids.ccattoolkit. language. and family members.pdf ■ Consolidated Culturalogical Assessment Tool (C-CAT) Tool Kit – The Ohio Department of Mental Health. this 123-page document is a Multicultural Access and Treatment Demonstration Project at Antioch University funded by the California Endowment.usf. (2006). and human resource personnel. It contains an excellent compilation of strategies to enhance cultural competence in mental health agencies.harvard. The C-CAT Tool Kit includes the C-CAT instruments. It is useful to agency and program administrators. It has its own training program that ‘flows’ from the scale. Sensitivity to Consumers: What does it mean to be a person of color AND a mental health consumer of services. pages 31-33 consists of an annotated bibliography of several individual cultural assessment tools. http://www. The CBMCS is a likert scale consisting of 21 items representing 4 factors: Multicultural Knowledge: Issues of acculturation. http://www. a stand-alone database.calendow. Monica Roizner. and Sociocultural Diversities: formerly (Nonethnic Ability) 88 . released the C-CAT.

Research on Social Work Practice. Staff and Stakeholder Commitment. T. The overall instrument had a Cronbach’s alpha of .. Research on the tool is published in the following citation: Cornelius. This project aims to assist clinicians in assessing the mental health of people from culturally and linguistically diverse backgrounds. Morrow. and ■ Compendium of Culturally-Sensitive Assessment Tools and Inventories – The West Australian Transcultural Mental Health Centre took part in a project that developed the Compendium of Culturally-Sensitive Assessment Tools and Inventories. ■ Consumer Based Cultural competence Inventory – Cornelius and colleagues developed a 52-item consumer assessment instrument of the cultural competence of mental health providers. (2004). http://www.75. Following a 2-year. Section Two sets forth nine guiding principles for culturally competent disaster mental health services and related recommendations for developing these services. The appendices provide an annotated bibliography of cultural competence resources and tools as well as a Cultural Competence Checklist for Disaster Crisis Counselling Programs. community-driven instrument development process.. Contact: 14(3):201-9. Section One also presents the Cultural Competence Continuum and a list of questions to address in a disaster mental health plan. and Morgan. Arthur. and disability. Arellano.. sexuality. N.. Booker. social class. Linguistic Competence.163-187.samhsa.wa. Standards and Contractual Requirements. L... G. and Vietnamese American mental health consumers across the state of Maryland. Cronbach’s Alpha of internal consistency ranges from .. M. Responsibility for Cultural Competence. R. 37(3). and Martenson. Dana. I. The validity and reliability testing of a consumer-based cultural competence inventory.Issues of comp. Cultural competence Revised: The California Brief Multicultural competence Scale. The categories include the Commissioner's Personal Leadership. Section One explores the nature of culture and disaster and discusses cultural competence in the context of disaster mental health services. ■ Developing Cultural Competence in Disaster Mental Health Programs: Guiding Principles and Recommendations . Measurement and Evaluation in Counseling and Development.This document is written by Drs. A. http://www.mentalhealth.nasmhpd. Cultural Competence Plan. Data Analysis. http://www. The assessment consists of questions appropriate for state mental health agencies in ten areas of cultural competence. aging. Organisational Self-Assessment. Cultural Competence Advisory Committee. L. Citation: Gamst. This guide includes two sections and six appendices. O.cbmcs. DerKarabetian. this consumer assessment tool was administered to 238 African American.pdf 89 .Thomas@health. Latino.. G.asp ■ State Mental Health Agency Cultural Competence Activities Assessment – This assessment was developed by the National Association of State Mental Health Program Directors and the National Technical Assistance Center for State Mental Health Planning based on discussion at two expert meetings. (2004).90 to . L. Athey and Moody-Williams.92.

91 were derived for the Multicultural Knowledge. and Multicultural Skills. peers. The MAKSS-CE-R was revised in 2003 to assess the impact of training on learners' multicultural counselling competence. B. 2) the accessibility of services and the willingness to negotiate on priorities for care. Coleman.. A. developed in 1990 which consisted of 60 self-report items on three subscales of knowledge. 3) 90 .. Racial Identity. Statistical analysis identified four core domains assessed by the instrument: as 1) the ability to tune into psycho-social. Citation: LaFromboise. P. 30: 153-80. (2003). Multicultural Terminology. Measurement and Evaluation in Counselling and Development. Knowledge. ■ Multicultural Awareness-Knowledge-and Skills Survey – Counsellor Edition. medical. Y. alphas of . L. B. S. The instrument was developed for use by counsellors and has been tested on both professional and trainee populations... and Skills Survey-Counsellor Edition. Multicultural Awareness. K. M. T. the MCCTS is a self-report instrument containing 32 behaviourally stated items and 29 items that require participants to provide information regarding their entry-level counselling training experiences and demographics such as gender.. skills and awareness.66. J. Utsey. A revision of the Multicultural Awareness. Multicultural Awareness. and Austin. respectively (the somewhat lower reliability coefficient for the Racial Identity subscale. The MAKSS-CE-R now consists 33 items (10 items each for the Awareness and Skills subscales and 13 items for the Knowledge subscale) Citation: Kim. is a 32-item self-report measure that assesses respondents' knowledge and awareness of multicultural competence. and Multicultural Skills subscales.. and year of graduation. Citation: Ponterotto.. ■ Multicultural Counselling Awareness Scale (MCAS) – The MCAS. a revision of the MCAS: B.. and . and D’Andrea. G. These authors assert that there were five factors underlying the multicultural counselling competence items of the MCCTS: Multicultural Knowledge. and as a self-assessment tool. K. S. race. and spiritual needs. ■ Multicultural Counselling Competence and Training Survey (MCCTS) – Developed by authors Holcomb-McCoy and Myers in 1999.■ Cross-cultural Counselling Inventory – Revised (CCCI-R) . Multicultural Terminology. The developers of the instrument suggest that it is best used for providing feedback during training – by faculty. . Knowledge of Racial Identity Development Theories. Cartwright. age.CCCI-R was originally created as an 18-item scale used by learners to rate the behaviour of a counsellor in a short video of a counselling session. This instrument has been cited in more than 75 scientific articles. . 22(5): 380-88. J. ■ MHA/MHP/CCAG – The Mental Hygiene Administration/Maryland Health Partners (MHA/MHP) Cultural competence Advisory Group (CCAG) developed a 52-item scale (still in progress) to assess clients' perceptions of the Public Mental Health System. Journal of Multicultural Counselling and Development. . H. 36: 161-80. and clients – during simulated or actual counselling sessions. Development and factor structure of the Cross-cultural Counseling Inventory – Revised. In the calculation of internal consistency reliability coefficients (Cronbach's alpha) for the instrument.79. Gretchen D. Asay. O. Revision of the Multicultural Counselling Awareness Scale. Rieger. (1991). D.. A. (2002). and Hernandez.Revised (MAKSS-CE-R) – The MAKSS-CE-R is a self-assessment instrument that is based on the MAKSS instrument. B. R.92.92. P. Professional Psychology: Research and Practice.

548-557. Z.. The central objective of the Tool is to ensure that the organisational culture and practice of mental health services effectively accommodates Western Australia’s growing multicultural population. Developing a Cultural Competence Assessment Tool for People in Recovery From Racial. E. and trustworthiness). (1982) on multicultural counseling competencies on the following four subscales: Awareness (ten items measure multicultural sensitivity.pdf 91 .healthsystem. Western Australia . (1994). and Relationship (eight items measure the interaction process with the minority patient for Challenges. MacLeod. critically examines the quantitative measures of cultural competence most commonly used in medicine and in the health professions and identifies underlying assumptions about what constitutes competent practice across social and cultural ■ Multicultural Counselling Inventory (MCI) – The MCI consists of 43 self-report items that assesses multicultural competencies on a 4-point Likert scale (1 = very inaccurate.efforts to reach out to racially diverse communities. ■ Measures of Cultural Competence: Examining Hidden Assumption – This article. http://www.243-50. S. Citation: Kumas-Tan. and advocacy in general life experiences and professional activities). Ethnic and Cultural Backgrounds: The Journey. Loppie. and to assist services in implementing cultural competence initiatives at all levels. Academic Medicine. and Lessons Learned. B. al (2007). The MCI is based on a conceptual framework from Sue et al. B. 4 = very accurate) asking the respondent to indicate the degree to which the scale items describe their work as counselors/trainers. Copies of the Cultural competence Standards and Self-Assessment Audit Tool may be obtained from the Mental Health Division. and Frank. 41.. and multicultural research).. Reeves.. Development of the Multicultural Counselling Inventory (MCI): A self-report measure of multicultural competencies.. ■ The Cultural competence Standards and Audit Tool (the Tool) – the Tool was developed and produced by the Multicultural Forum for Mental Health Practitioners. C. Taffe. C. Journal of Counselling Psychology. G. Knowledge (eleven items measure treatment planning. T. et al. (2007). Morgan. Citation: T.virginia. 137-148.. A. and world view.pp. The Performance Measures in the Tool were designed to have three functions: to measure the extent to which services can achieve the Cultural competence Standards. interactions. This Western Australia based group of mental health clinicians was a policy and advisory group to the state’s mental health directorate on issues concerning service development and provisions for Western Australia’s Culturally and Linguistically Diverse (CALD) mental health consumers. I. Department of Health. and 4) the willingness to listen to and respect people in recovery from various cultures. 82(6).. Psychiatric Rehabilitation Journal. case conceptualization. To learn more about this tool. Citation: Sodowsky.08 9222 4222. Gutkin. comfort level. Measures of Cultural Competence: Examining Hidden Assumptions.mmha. Skills (fourteen items measure general and specific multicultural skills). (2005). Beagan. please visit: http://www. to guide services in how to strive for best practice and quality-assured service provisions to CALD communities. authored by Kumas-Tan et. 28(3):pp.