**Appendix D.1**

**Cultural Competency Assessment Tool for Hospitals (CCATH) Draft Used
in Pilot Test**

**Culturally Competent Care**

> ***Statement of Confidentiality***
>
> Any information that identifies you or your hospital will be kept
> confidential and used only for the purposes of this study. RAND will
> not release any information that identifies you without your prior
> consent, except as required by law.
>
> If you have questions about this study or your participation, please
> call the RAND Survey Coordinator, Kelly Sand, at 1-310-393-0411 ext.
> 7479.

  -----------------------------------------------------------------------
  **Survey Instructions**

  -----------------------------------------------------------------------

**Your hospital has been selected as a test health care facility to aid
in the design of Cultural Competency Assessment Tool for Hospitals
(CCATH). The Office of Minority Health, a federal agency within the U.S.
Department of Health and Human Services, sponsors this research.**

**You have received this survey booklet because a representative of your
hospital agreed to help us to test the Culturally Competent Care Survey.
As you fill out the booklet, please keep in mind that the information
you provide will be kept confidential. Below are some useful
instructions.**

a.  Please answer the questions in this survey booklet about the
    hospital where you received this survey.

b.  This survey covers several topics related to your role at this
    hospital. For a full list of the topics, please see the table of
    contents on the following page.

c.  If you are not sure how to answer a question or if your answer does
    not fit the choices we have listed, please make a note in the margin
    or at the end of the survey. Because we are testing our survey, your
    comments will help us to understand where and how we need to make
    changes.

d.  Please answer each question, unless you are instructed to skip to a
    specific question. When you should skip over a question, you'll see
    an instruction that looks like this:

> **Is today Tuesday?**
>
> ~1~ Yes
>
> ~2~ No *IF NO, Go to Question 1*

e.  If you have any questions or need more information please call the
    RAND Survey Coordinator, Kelly Sand, at 1-310-393-0411, extension
    7479.

f.  When you have completed this survey booklet, please use the
    postage-paid envelope to return it to:

RAND

Attn: Kelly Sand

1700 Main Street

PO Box 2138

Santa Monica, CA 90407-2138

**Table of Contents**

### 

Section A: The Staff's Delivery of Culturally and Linguistically
Appropriate Care 1

Section B: The Hospital Climate and the Community 4

Section C: Collection of Cultural and Linguistic Information 5

Section D: Climate 8

Section E: Personal Information 9

### 

### **Section A**

### **The Staff's Delivery of Culturally and Linguistically Appropriate Care**

1.  Culturally appropriate care includes incorporating the health
    related beliefs and cultural values of in-patients into the
    diagnosis and treatment decisions. Does this hospital have a formal
    process to assess the ability of staff to deliver culturally
    appropriate care?

> ~0~ No IF NO, Go to Question 4
>
> ~1~ Yes

2.  How is the information on the ability of staff to deliver culturally
    appropriate care used?

> ***(Check All That Apply)***

~1~ Input for Performance Evaluation

~2~ Factor in Bonus or Merit Pay

~3~ Something else (Please Specify):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. How does this hospital assess the ability of the staff to deliver
culturally appropriate care?

+-----------------------+-----+--------+------+------+------+------+
|                       |     |        | *    |      |      |      |
|                       |     |        | [How |      |      |      |
|                       |     |        | o    |      |      |      |
|                       |     |        | ften |      |      |      |
|                       |     |        | is   |      |      |      |
|                       |     |        | the  |      |      |      |
|                       |     |        | s    |      |      |      |
|                       |     |        | taff |      |      |      |
|                       |     |        | ass  |      |      |      |
|                       |     |        | esse |      |      |      |
|                       |     |        | d?]{ |      |      |      |
|                       |     |        | .und |      |      |      |
|                       |     |        | erli |      |      |      |
|                       |     |        | ne}* |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
|                       | [   | [Yes]  | Less | Once | T    | More |
|                       | No] | {.unde | Than | Per  | wice | Than |
|                       | {.u | rline} |      |      | Per  |      |
|                       | nde |        | Once | [Y   |      | T    |
|                       | rli |        | Per  | ear] | [Y   | wice |
|                       | ne} |        |      | {.un | ear] | Per  |
|                       |     |        | [Y   | derl | {.un |      |
|                       |     |        | ear] | ine} | derl | [Y   |
|                       |     |        | {.un |      | ine} | ear] |
|                       |     |        | derl |      |      | {.un |
|                       |     |        | ine} |      |      | derl |
|                       |     |        |      |      |      | ine} |
+-----------------------+-----+--------+------+------+------+------+
| a\. Written or        | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| computerized test     |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| b\. Observation and   | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| rating of             |     | YES    |      |      |      |      |
| staff/patient         |     |        |      |      |      |      |
| interaction           |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| c\. Consumer          | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| satisfaction with     |     | YES    |      |      |      |      |
| individual            |     |        |      |      |      |      |
|                       |     |        |      |      |      |      |
| in-patient encounters |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| d\. Some other way    | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
|                       |     | YES    |      |      |      |      |
| *(Please specify)*    |     |        |      |      |      |      |
| \_\_\_\_\_\           |     |        |      |      |      |      |
| _\_\_\_\_\_\_\_\_\_\_ |     |        |      |      |      |      |
|                       |     |        |      |      |      |      |
| *\_                   |     |        |      |      |      |      |
| \_\_\_\_\_\_\_\_\_\_\ |     |        |      |      |      |      |
| _\_\_\_\_\_\_\_\_\_\_ |     |        |      |      |      |      |
| \_\_\_\_\_\_\_\_\_\_* |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+

4\. Linguistically appropriate care includes identifying and minimizing
language barriers when communicating with patients. Does this hospital
have a formal process to assess the ability of staff to deliver
linguistically appropriate care?

> ~0~ No IF NO, Go to Question 7
>
> ~1~ Yes

5\. How is the information on the ability of staff to deliver
linguistically appropriate care used?

> ***(Check All That Apply)***
>
> ~1~ Input for Performance Evaluation
>
> ~2~ Factor in Bonus or Merit Pay
>
> ~3~ Something else (Please Specify):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6\. How does this hospital assess the ability of the staff to deliver
linguistically appropriate care?

+-----------------------+-----+--------+------+------+------+------+
|                       |     |        | *    |      |      |      |
|                       |     |        | [How |      |      |      |
|                       |     |        | o    |      |      |      |
|                       |     |        | ften |      |      |      |
|                       |     |        | is   |      |      |      |
|                       |     |        | the  |      |      |      |
|                       |     |        | s    |      |      |      |
|                       |     |        | taff |      |      |      |
|                       |     |        | ass  |      |      |      |
|                       |     |        | esse |      |      |      |
|                       |     |        | d?]{ |      |      |      |
|                       |     |        | .und |      |      |      |
|                       |     |        | erli |      |      |      |
|                       |     |        | ne}* |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
|                       | [   | [Yes]  | Less | Once | T    | More |
|                       | No] | {.unde | Than | Per  | wice | Than |
|                       | {.u | rline} |      |      | Per  |      |
|                       | nde |        | Once | [Y   |      | T    |
|                       | rli |        | Per  | ear] | [Y   | wice |
|                       | ne} |        |      | {.un | ear] | Per  |
|                       |     |        | [Y   | derl | {.un |      |
|                       |     |        | ear] | ine} | derl | [Y   |
|                       |     |        | {.un |      | ine} | ear] |
|                       |     |        | derl |      |      | {.un |
|                       |     |        | ine} |      |      | derl |
|                       |     |        |      |      |      | ine} |
+-----------------------+-----+--------+------+------+------+------+
| a\. Written or        | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| computerized test     |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| b\. Observation and   | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| rating of             |     | YES    |      |      |      |      |
| staff/patient         |     |        |      |      |      |      |
| interaction           |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| c\. Consumer          | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| satisfaction with     |     | YES    |      |      |      |      |
| individual            |     |        |      |      |      |      |
|                       |     |        |      |      |      |      |
| in-patient encounters |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| d\. Some other way    | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
|                       |     | YES    |      |      |      |      |
| *(Please specify)*    |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

7\. Does the staff at the Hospital:

***(Check One Box in Each Row)***

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Identify cultural and linguistic needs of patients ~0~                ~1~
  in the admission screening?                                               

  b\. Identify cultural and linguistic needs during the  ~0~                ~1~
  discharge planning?                                                       

  c\. Accommodate the ethnic/cultural dietary            ~0~                ~1~
  preferences of patients?                                                  

  d\. Incorporate information or knowledge about         ~0~                ~1~
  cultural beliefs into patient educational materials?                      

  e\. Use clinical guidelines that incorporate           ~0~                ~1~
  information about cultural beliefs?                                       

  f\. Use diagnostic tools that address differences of   ~0~                ~1~
  culture or language?                                                      
  ------------------------------------------------------ ------------------ -------------------

### 

### **Section B**

### **The Hospital Climate and the Community**

8\. Do the public areas of this hospital have posters, photographs, and
artwork that reflect different populations residing in the service area?

> ~0~ No
>
> ~1~ Yes

9\. Does the hospital have special events to recognize diverse racial
and ethnic heritages?

> ~0~ No
>
> ~1~ Yes

10\. Does this hospital post signs providing directions in languages
other than English?

> ~0~ No IF NO, Go to Question 12
>
> ~1~ Yes

11\. In what languages are the signs posted?

***(Check One Box in Each Row)***

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Spanish                                            ~0~                ~1~

  b\. Chinese                                            ~0~                ~1~

  c\. Vietnamese                                         ~0~                ~1~

  d\. Korean                                             ~0~                ~1~

  e\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  f\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  g\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      
  ------------------------------------------------------ ------------------ -------------------

###  

### 

### 

### **Section C**

### **Collection of Cultural and Linguistic Information**

12\. Does this hospital collect any ethnicity or racial data on
individuals receiving in-patient services?

> ~0~ No IF NO, Go to Question 17
>
> ~1~ Yes

13\. What percentage of this hospital\'s in-patient population is in the
following racial or ethnic categories? 

***(Check One Box in Each Line)***

  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                   [Non]{.underline}e   [1% -             [6% -              [16% -             [26% -             More Than
                                                        5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. Hispanic or Latino           ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  Non-Hispanic:                                                                                                                    

  b\. Asian                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  c\. American Indian or Alaska    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Native                                                                                                                           

  d\. Black or African American    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  e\. Native Hawaiian or other     ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Pacific Islander                                                                                                                 

  f\. White                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  g\. Other (please specify)       ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                                                   
  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------

14\. How often is inpatient-level data on ethnicity or race collected?

> ***(Check All That Apply)***
>
> ~1~ For each in-patient at admission
>
> ~2~ For special projects
>
> ~3~ Other (please specify):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

15\. What method does this hospital use to collect race or ethnicity of
individuals receiving in-patient services?

> ~1~ Patient self-report only
>
> ~2~ Staff observation only
>
> ~3~ Both patient self-report and staff observation

16\. Is patient-level data on race or ethnicity maintained in the paper
medical record or an electronic management information system (MIS)?

> ~1~ Paper medical record only
>
> ~2~ Electronic MIS only
>
> ~3~ Both paper record and electronic MIS

17\. Does this hospital collect data on the preferred language for
individuals receiving in-patient services?

> ~0~ No IF NO, Go to Question 21
>
> ~1~ Yes

18\. What percentage of this hospital\'s in-patient population is in the
following language categories?

***(Check One Box in Each Line)***

  ---------------------------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                           [1% -             [6% -              [16% -             [26% -             More Than
                                           5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. English                              ~1~               ~2~                ~3~                ~4~                ~5~

  b\. Spanish                              ~1~               ~2~                ~3~                ~4~                ~5~

  c\. Chinese                              ~1~               ~2~                ~3~                ~4~                ~5~

  d\. Vietnamese                           ~1~               ~2~                ~3~                ~4~                ~5~

  e\. Korean                               ~1~               ~2~                ~3~                ~4~                ~5~

  f\. Other (please specify)               ~1~               ~2~                ~3~                ~4~                ~5~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              

  g\. Other (please specify)               ~1~               ~2~                ~3~                ~4~                ~5~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              

  h\. Other (please specify)               ~1~               ~2~                ~3~                ~4~                ~5~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              
  ---------------------------------------- ----------------- ------------------ ------------------ ------------------ -------------------

19\. How often is inpatient-level data on preferred language collected?

> ***(Check All That Apply)***
>
> ~1~ For each in-patient at admission
>
> ~2~ For special projects
>
> ~3~ Other (please specify):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

20\. Is patient-level data on preferred language maintained in the paper
medical record or an electronic management information system (MIS)?

> ~1~ Paper medical record only
>
> ~2~ Electronic MIS only
>
> ~3~ Both paper record and electronic MIS

### 

### **Section D**

### **Climate**

21\. How true or false are the following statements about this hospital?

***(Check One Box on Each Line)***

+---------------------------------------+------+------+------+------+
|                                       | De   | Some | Some | De   |
|                                       | fini | what | what | fini |
|                                       | tely |      |      | tely |
|                                       |      | [Fa  | [T   |      |
|                                       | [Fa  | lse] | rue] | [T   |
|                                       | lse] | {.un | {.un | rue] |
|                                       | {.un | derl | derl | {.un |
|                                       | derl | ine} | ine} | derl |
|                                       | ine} |      |      | ine} |
+---------------------------------------+------+------+------+------+
| a\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| speak with enthusiasm\                |      |      |      |      |
| and commitment to the organization's  |      |      |      |      |
| agenda for a culturally\              |      |      |      |      |
| diverse work force                    |      |      |      |      |
+---------------------------------------+------+------+------+------+
| b\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| promote a culturally diverse work     |      |      |      |      |
| force as a competitive advantage      |      |      |      |      |
+---------------------------------------+------+------+------+------+
| c\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| promote culturally competent care as  |      |      |      |      |
| a competitive advantage               |      |      |      |      |
+---------------------------------------+------+------+------+------+
| d\. This hospital not only tolerates  | ~1~  | ~2~  | ~3~  | ~4~  |
| but also values differences people    |      |      |      |      |
| bring to the workplace                |      |      |      |      |
+---------------------------------------+------+------+------+------+

### 

### 

### 

### 

### 

###  

### 

### **Section E**

### **Personal Information**

The next few questions will help us to better design this survey and to
ensure it goes to the correct hospital representative.

22\. What is your job title at the hospital?

23\. What are your main duties and responsibilities?

24\. Do you have access to the internet while at work?

> ~0~ No
>
> ~1~ Yes

25\. How many years have you been employed at the hospital?

\_\_\_\_\_\_\_ Number of Years

26\. In the future would it be easier to complete a survey like this...

> ~1~ Over the phone
>
> ~2~ Through the internet, or
>
> ~3~ On paper (like this one)?

27\. Did you find any questions or sections hard to complete?

> ~0~ No
>
> ~1~ Yes IF YES, (Please describe)

28\. Did you require any assistance from another department in answering
any of these questions?

> ~0~ No
>
> ~1~ Yes IF YES, Which questions or sections? (Please describe)

29\. What department(s) did you get assistance from?

30\. May we contact you at a later time to ask you some question about
this survey?

> ~0~ No
>
> ~1~ Yes
>
> Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Phone
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Thanks for taking the time to complete this survey. Please use the
postage-paid envelope to return this survey to:

RAND

Attn: Kelly Sand

1700 Main Street

Santa Monica, CA 90407-2138

## 

####### Human Resource Management

***Statement of Confidentiality***

Any information that identifies you or your hospital will be kept
confidential and used only for the purposes of this study. RAND will not
release any information that identifies you without your prior consent,
except as required by law.

If you have questions about this study or your participation, please
call the RAND Survey Coordinator, Kelly Sand, at

1-310-393-0411 ext. 7479.

**Survey Instructions**

**Your hospital has been selected as a test health care facility to aid
in the design of Cultural Competency Assessment Tool for Hospitals
(CCATH). The Office of Minority Health, a federal agency within the U.S.
Department of Health and Human Services, sponsors this research.**

**You have received this survey booklet because a representative of your
hospital agreed to help us to test the Human Resource Management Survey.
As you fill out the booklet, please keep in mind that the information
you provide will be kept confidential. Below are some useful
instructions.**

a.  Please answer the questions in this survey booklet about the
    hospital where you received this survey.

b.  This survey covers several topics related to your role at this
    hospital. For a full list of the topics, please see the table of
    contents on the following page.

c.  If you are not sure how to answer a question or if your answer does
    not fit the choices we have listed, please make a note in the margin
    or at the end of the survey. Because we are testing our survey, your
    comments will help us to understand where and how we need to make
    changes.

d.  Please answer each question, unless you are instructed to skip to a
    specific question. When you should skip over a question, you'll see
    an instruction that looks like this:

> **Is today Tuesday?**
>
> ~1~ Yes
>
> ~2~ No *If No, Go to Question 1*

e.  If you have any questions or need more information please call the
    RAND Survey Coordinator, Kelly Sand, at

1-310-393-0411 ext 7479.

f.  When you have completed this survey booklet, please use the
    postage-paid envelope to return it to:

RAND

Attn: Kelly Sand

PO Box 2138

Santa Monica, CA 90407-2138

## 

## 

**Table of Contents**

### 

Section A: Recruitment and Departure 1

Section B: Benefits and Reviews 3

Section C: Climate 5

Section D: Diversity of Hospital Staff 6

Section E: Work Environment 10

Section F: Training 11

Section G: Personal Information 15

## 

### **Section A**

### **Recruitment and Departure**

1\. Which of the following does this hospital use to recruit staff?

+-----------------------------+-------+-----------+---------+---------+
|                             |       |           | *Which  |         |
|                             |       |           | type of |         |
|                             |       |           | staff,* |         |
|                             |       |           |         |         |
|                             |       |           | *m      |         |
|                             |       |           | edical, |         |
|                             |       |           | non-    |         |
|                             |       |           | medical |         |
|                             |       |           | staff,  |         |
|                             |       |           | or      |         |
|                             |       |           | both?   |         |
|                             |       |           | \*\*\** |         |
+-----------------------------+-------+-----------+---------+---------+
|                             | [     | [Yes]{.u  | Medical | Non-    |
|                             | No]{. | nderline} |         | medical |
|                             | under |           | [Staf   | [Staf   |
|                             | line} |           | ]{.unde | f]{.und |
|                             |       |           | rline}f | erline} |
+-----------------------------+-------+-----------+---------+---------+
| a\. Newspaper, radio, and   | ~0~   | ~1~ IF    | ~1~     | ~2~     |
| other media                 |       | YES       |         |         |
|                             |       |           |         |         |
| serving diverse communities |       |           |         |         |
+-----------------------------+-------+-----------+---------+---------+
| b\. Community-based ethnic  | ~0~   | ~1~ IF    | ~1~     | ~2~     |
| organizations               |       | YES       |         |         |
+-----------------------------+-------+-----------+---------+---------+
| c\. Informal networks and   | ~0~   | ~1~ IF    | ~1~     | ~2~     |
| coalitions                  |       | YES       |         |         |
+-----------------------------+-------+-----------+---------+---------+
| d\. Individuals from        | ~0~   | ~1~ IF    | ~1~     | ~2~     |
| diverse communities         |       | YES       |         |         |
+-----------------------------+-------+-----------+---------+---------+
| e\. Hospital staff or       | ~0~   | ~1~ IF    | ~1~     | ~2~     |
| volunteers from\            |       | YES       |         |         |
| diverse communities         |       |           |         |         |
+-----------------------------+-------+-----------+---------+---------+
| f\. Outreach to colleges,   | ~0~   | ~1~ IF    | ~1~     | ~2~     |
| nursing schools, and        |       | YES       |         |         |
| medical schools             |       |           |         |         |
+-----------------------------+-------+-----------+---------+---------+
| g\. Outreach to high school | ~0~   | ~1~ IF    | ~1~     | ~2~     |
| students in\                |       | YES       |         |         |
| diverse communities         |       |           |         |         |
+-----------------------------+-------+-----------+---------+---------+

> \*\*\* Note: Medical staff includes physicians, nurses, and allied
> health personnel. Non-medical staff includes administrative and
> support staff

2\. Does this hospital conduct exit interviews or track reasons for
leaving?

> ~0~ No IF NO, Go to Question 5
>
> ~1~ Yes

3\. For which types of staff?

> ***(Check All That Apply)***
>
> ~1~ Top Management
>
> ~2~ Department Heads and Supervisors
>
> ~3~ Medical staff (non-management)
>
> ~4~ Non-medical staff (non-management)

4\. How is the exit interview data used?

> ***(Check All That Apply)***
>
> ~1~ Make changes to human resource policies and practices
>
> ~2~ Improve the organizational climate
>
> ~3~ Make changes to staff benefit package
>
> ~4~ Reviewed by top management as an indicator of department
> performance
>
> ~5~ Monitor staff turnover by race or ethnicity

### 

### **Section B**

### **Benefits and Reviews**

### 

5\. Which of the following benefits are available to medical and
non-medical staff?

+-------------------+-----+---------+-------+-------+-------+-------+
|                   |     |         | *[    |       |       |       |
|                   |     |         | Which |       |       |       |
|                   |     |         | types |       |       |       |
|                   |     |         | of    |       |       |       |
|                   |     |         | staff |       |       |       |
|                   |     |         | are   |       |       |       |
|                   |     |         | eli   |       |       |       |
|                   |     |         | gible |       |       |       |
|                   |     |         | for   |       |       |       |
|                   |     |         | these |       |       |       |
|                   |     |         | ben   |       |       |       |
|                   |     |         | efits |       |       |       |
|                   |     |         | ?]{.u |       |       |       |
|                   |     |         | nderl |       |       |       |
|                   |     |         | ine}* |       |       |       |
+-------------------+-----+---------+-------+-------+-------+-------+
|                   | [   | [Ye     | Top   | Depar | Me    | N     |
|                   | No] | s]{.und | Manag | tment | dical | on-Me |
|                   | {.u | erline} | ement | H     | Staff | dical |
|                   | nde |         |       | eads/ | (     | Staff |
|                   | rli |         |       |       | non-m | (     |
|                   | ne} |         |       | S     | anage | non-m |
|                   |     |         |       | uperv | ment) | anage |
|                   |     |         |       | isors |       | ment) |
+-------------------+-----+---------+-------+-------+-------+-------+
| a\. Formal        | ~0~ | ~1~ IF  | ~1~   | ~2~   | ~3~   | ~4~   |
| mentoring program |     | YES     |       |       |       |       |
+-------------------+-----+---------+-------+-------+-------+-------+
| b\. Informal      | ~0~ | ~1~ IF  | ~1~   | ~2~   | ~3~   | ~4~   |
| mentoring program |     | YES     |       |       |       |       |
+-------------------+-----+---------+-------+-------+-------+-------+
| c\. Management    | ~0~ | ~1~ IF  | ~1~   | ~2~   | ~3~   | ~4~   |
| training          |     | YES     |       |       |       |       |
+-------------------+-----+---------+-------+-------+-------+-------+
| d\. Tuition       | ~0~ | ~1~ IF  | ~1~   | ~2~   | ~3~   | ~4~   |
| assistance or     |     | YES     |       |       |       |       |
| tuition           |     |         |       |       |       |       |
| reimbursement for |     |         |       |       |       |       |
| ongoing education |     |         |       |       |       |       |
+-------------------+-----+---------+-------+-------+-------+-------+
| e\. Personal      | ~0~ | ~1~ IF  | ~1~   | ~2~   | ~3~   | ~4~   |
| counseling or     |     | YES     |       |       |       |       |
| employee\         |     |         |       |       |       |       |
| assistance        |     |         |       |       |       |       |
| programs          |     |         |       |       |       |       |
+-------------------+-----+---------+-------+-------+-------+-------+
| f\. Flexible      | ~0~ | ~1~ IF  | ~1~   | ~2~   | ~3~   | ~4~   |
| (cafeteria style) |     | YES     |       |       |       |       |
|                   |     |         |       |       |       |       |
| benefits          |     |         |       |       |       |       |
+-------------------+-----+---------+-------+-------+-------+-------+
| g\. Affinity      | ~0~ | ~1~ IF  | ~1~   | ~2~   | ~3~   | ~4~   |
| (networking)      |     | YES     |       |       |       |       |
| groups for        |     |         |       |       |       |       |
| racial/ethnic     |     |         |       |       |       |       |
| minority staff    |     |         |       |       |       |       |
+-------------------+-----+---------+-------+-------+-------+-------+
| h\. Work/life     | ~0~ | ~1~ IF  | ~1~   | ~2~   | ~3~   | ~4~   |
| balance programs  |     | YES     |       |       |       |       |
| such as flextime, |     |         |       |       |       |       |
| job sharing, or   |     |         |       |       |       |       |
| telecommuting     |     |         |       |       |       |       |
+-------------------+-----+---------+-------+-------+-------+-------+
| i\. Compensatory  | ~0~ | ~1~ IF  | ~1~   | ~2~   | ~3~   | ~4~   |
| pay for bilingual |     | YES     |       |       |       |       |
| staff             |     |         |       |       |       |       |
+-------------------+-----+---------+-------+-------+-------+-------+

6\. Are contributions to this hospital's goals for cultural diversity:

***(Check One Box in Each Row)***

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Considered in all top managers' annual performance ~0~                ~1~
  review?                                                                   

  b\. A factor in all top managers' compensation         ~0~                ~1~
  package?                                                                  

  c\. Considered in all department heads' and            ~0~                ~1~
  supervisors' annual performance review?                                   

  d\. A factor in all department heads' and supervisors' ~0~                ~1~
  compensation package?                                                     

  e\. Considered in all (non-management) staff's annual  ~0~                ~1~
  performance review?                                                       

  f\. A factor in all (non-management) staff's           ~0~                ~1~
  compensation package?                                                     
  ------------------------------------------------------ ------------------ -------------------

### **Section C**

### **Climate**

7\. How true or false are the following statements about this hospital?

***(Check One Box on Each Line)***

+---------------------------------------+------+------+------+------+
|                                       | De   | Some | Some | De   |
|                                       | fini | what | what | fini |
|                                       | tely |      |      | tely |
|                                       |      | [Fa  | [T   |      |
|                                       | [Fa  | lse] | rue] | [T   |
|                                       | lse] | {.un | {.un | rue] |
|                                       | {.un | derl | derl | {.un |
|                                       | derl | ine} | ine} | derl |
|                                       | ine} |      |      | ine} |
+---------------------------------------+------+------+------+------+
| a\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| speak with enthusiasm\                |      |      |      |      |
| and commitment to the organization's  |      |      |      |      |
| agenda for a culturally\              |      |      |      |      |
| diverse work force                    |      |      |      |      |
+---------------------------------------+------+------+------+------+
| b\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| promote a culturally diverse work     |      |      |      |      |
| force as a competitive advantage      |      |      |      |      |
+---------------------------------------+------+------+------+------+
| c\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| promote culturally competent care as  |      |      |      |      |
| a competitive advantage               |      |      |      |      |
+---------------------------------------+------+------+------+------+
| d\. This hospital not only tolerates  | ~1~  | ~2~  | ~3~  | ~4~  |
| but also values differences people    |      |      |      |      |
| bring to the workplace                |      |      |      |      |
+---------------------------------------+------+------+------+------+
| e\. The turnover rate among           | ~1~  | ~2~  | ~3~  | ~4~  |
| racial/ethnic minorities in the       |      |      |      |      |
| management staff is higher than that  |      |      |      |      |
| of whites                             |      |      |      |      |
+---------------------------------------+------+------+------+------+
| f\. The turnover rate among           | ~1~  | ~2~  | ~3~  | ~4~  |
| racial/ethnic minorities in the       |      |      |      |      |
| medical staff (non-management) is     |      |      |      |      |
| higher than that of whites            |      |      |      |      |
+---------------------------------------+------+------+------+------+
| g\. The turnover rate among           | ~1~  | ~2~  | ~3~  | ~4~  |
| racial/ethnic minorities in the       |      |      |      |      |
| non-medical staff (non-management) is |      |      |      |      |
| higher than that of whites            |      |      |      |      |
+---------------------------------------+------+------+------+------+

### **Section D**

### **Diversity of Hospital Staff**

8\. Does this hospital track the race or ethnicity of its work force?

> ~0~ No IF NO, Go to Question 16
>
> ~1~ Yes

9\. What percentage of this hospital's work force is in the following
racial or ethnic categories?

***(Check One Box in Each Line)***

  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                   [Non]{.underline}e   [1% -             [6% -              [16% -             [26% -             More Than
                                                        5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. Hispanic or Latino           ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  Non-Hispanic:                                                                                                                    

  b\. Asian                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  c\. American Indian or Alaska    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Native                                                                                                                           

  d\. Black or African American    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  e\. Native Hawaiian or other     ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Pacific Islander                                                                                                                 

  f\. White                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  g\. Other (please specify)       ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                                                   
  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------

10\. What percentage of this hospital's physicians is in the following
racial or ethnic categories?

***(Check One Box in Each Line)***

  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                   [Non]{.underline}e   [1% -             [6% -              [16% -             [26% -             More Than
                                                        5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. Hispanic or Latino           ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  Non-Hispanic:                                                                                                                    

  b\. Asian                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  c\. American Indian or Alaska    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Native                                                                                                                           

  d\. Black or African American    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  e\. Native Hawaiian or other     ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Pacific Islander                                                                                                                 

  f\. White                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  g\. Other (please specify)       ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                                                   
  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------

11\. What percentage of this hospital's registered nurses is in the
following racial or ethnic categories?

***(Check One Box in Each Line)***

  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                   [Non]{.underline}e   [1% -             [6% -              [16% -             [26% -             More Than
                                                        5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. Hispanic or Latino           ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  Non-Hispanic:                                                                                                                    

  b\. Asian                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  c\. American Indian or Alaska    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Native                                                                                                                           

  d\. Black or African American    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  e\. Native Hawaiian or other     ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Pacific Islander                                                                                                                 

  f\. White                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  g\. Other (please specify)       ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                                                   
  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------

12\. What percentage of this hospital's allied health professionals
(such as speech, occupational, and physical therapists) is in the
following racial or ethnic categories?

***(Check One Box in Each Line)***

  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                   [Non]{.underline}e   [1% -             [6% -              [16% -             [26% -             More Than
                                                        5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. Hispanic or Latino           ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  Non-Hispanic:                                                                                                                    

  b\. Asian                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  c\. American Indian or Alaska    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Native                                                                                                                           

  d\. Black or African American    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  e\. Native Hawaiian or other     ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Pacific Islander                                                                                                                 

  f\. White                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  g\. Other (please specify)       ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                                                   
  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------

13\. What percentage of this hospital's department heads and supervisors
is in the following racial or ethnic categories?

***(Check One Box in Each Line)***

  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                   [Non]{.underline}e   [1% -             [6% -              [16% -             [26% -             More Than
                                                        5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. Hispanic or Latino           ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  Non-Hispanic:                                                                                                                    

  b\. Asian                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  c\. American Indian or Alaska    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Native                                                                                                                           

  d\. Black or African American    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  e\. Native Hawaiian or other     ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Pacific Islander                                                                                                                 

  f\. White                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  g\. Other (please specify)       ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                                                   
  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------

14\. What percentage of this hospital's top management (CEO, COO, Sr.
Vice Presidents, Vice Presidents) is in the following racial or ethnic
categories?

***(Check One Box in Each Line)***

  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                   [Non]{.underline}e   [1% -             [6% -              [16% -             [26% -             More Than
                                                        5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. Hispanic or Latino           ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  Non-Hispanic:                                                                                                                    

  b\. Asian                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  c\. American Indian or Alaska    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Native                                                                                                                           

  d\. Black or African American    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  e\. Native Hawaiian or other     ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Pacific Islander                                                                                                                 

  f\. White                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  g\. Other (please specify)       ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                                                   
  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------

15\. What percentage of the hospital's board of trustees is in the
following racial or ethnic categories?

***(Check One Box in Each Line)***

  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                   [Non]{.underline}e   [1% -             [6% -              [16% -             [26% -             More Than
                                                        5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. Hispanic or Latino           ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  Non-Hispanic:                                                                                                                    

  b\. Asian                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  c\. American Indian or Alaska    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Native                                                                                                                           

  d\. Black or African American    ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  e\. Native Hawaiian or other     ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  Pacific Islander                                                                                                                 

  f\. White                        ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~

  g\. Other (please specify)       ~0~                  ~1~               ~2~                ~3~                ~4~                ~5~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                                                   
  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------

###  **Section E**

### **Work Environment**

16\. Does this hospital conduct employee satisfaction surveys?

> ~0~ No IF NO, Go to Question 20
>
> ~1~ Yes

17\. For which types of staff?

> ***(Check All That Apply)***
>
> ~1~ Top Management
>
> ~2~ Department Heads and Supervisors
>
> ~3~ Medical staff (non-management)
>
> ~4~ Non-medical staff (non-management)

18\. Does the employee satisfaction survey address issues of diversity
climate?

> ~0~ No
>
> ~1~ Yes

19\. How is the employee satisfaction survey data used?

> ***(Check All That Apply)***
>
> ~1~ Make changes to human resource policies and practices
>
> ~2~ Improve the organizational climate
>
> ~3~ Make changes to staff benefit package
>
> ~4~ Reviewed by top management as an indicator of department
> performance
>
> ~5~ Monitor staff turnover by race or ethnicity
>
> ~6~ Other (please specify)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

### **Section F**

### **Training**

20\. Does this hospital have a systematic training program on cultural
and linguistic diversity? Note: A systematic training program consists
of a formal, ongoing training program, which may consist of either a
stand-alone training program or several training components integrated
into other types of training.

> ~0~ No IF NO, Go to Question 31
>
> ~1~ Yes

21\. Is the training program voluntary or mandatory?

> ~0~ Voluntary Approximately what percentage of the hospital staff
> attend the voluntary training? \_\_\_\_\_\_\_\_%
>
> ~1~ Mandatory Approximately what percentage of the hospital staff
> attend the mandatory training? \_\_\_\_\_\_\_\_%

22\. Is it a stand alone training program, or is cultural and linguistic
diversity training integrated into other types of training?

> ~1~ Stand alone only
>
> ~2~ Integrated with other training only
>
> ~3~ Both stand alone and integrated with other training

23\. Does training programs incorporate any credits for continuing
medical education (CME) or continuing education units (CEU)?

> ~0~ No IF NO, Go to Question 25
>
> ~1~ Yes

24\. What types of credits are offered?

> ~1~ CME credits only
>
> ~2~ CEU credits only
>
> ~3~ Both CME and CEU credits

25\. Which of the following types of staff participate in training that
includes information on cultural and linguistic differences?

***(Check One Box in Each Row)***

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Board of trustees                                  ~0~                ~1~

  b\. Top Management (CEO, COO, and VPs                  ~0~                ~1~

  c\. Department heads and Supervisors                   ~0~                ~1~

  d\. Physicians                                         ~0~                ~1~

  e\. Nurses                                             ~0~                ~1~

  f\. Allied health staff                                ~0~                ~1~

  g\. Other support staff                                ~0~                ~1~

  h\. Volunteer staff                                    ~0~                ~1~

  i\. Contract staff                                     ~0~                ~1~
  ------------------------------------------------------ ------------------ -------------------

26. Which of the following types of training are available for
    in-patient care staff?

+-------------------------+----+--------+--------+-----+---+------+---+
|                         |    |        | *[How  |     |   |      |   |
|                         |    |        | often  |     |   |      |   |
|                         |    |        | are    |     |   |      |   |
|                         |    |        | tr     |     |   |      |   |
|                         |    |        | aining |     |   |      |   |
|                         |    |        | u      |     |   |      |   |
|                         |    |        | pdates |     |   |      |   |
|                         |    |        | o      |     |   |      |   |
|                         |    |        | ffered |     |   |      |   |
|                         |    |        | in     |     |   |      |   |
|                         |    |        | these  |     |   |      |   |
|                         |    |        | ar     |     |   |      |   |
|                         |    |        | eas?]{ |     |   |      |   |
|                         |    |        | .under |     |   |      |   |
|                         |    |        | line}* |     |   |      |   |
+-------------------------+----+--------+--------+-----+---+------+---+
|                         | [N | [Yes]  | Only   | Ev  | O | More |   |
|                         | o] | {.unde | once   | ery | n | than |   |
|                         | {. | rline} | during | cou | c | [    |   |
|                         | un |        | new    | ple | e | once |   |
|                         | de |        | em     | [of |   | per  |   |
|                         | rl |        | ployee | yea | [ | y    |   |
|                         | in |        | [tr    | rs] | p | ear] |   |
|                         | e} |        | aining | {.u | e | {.un |   |
|                         |    |        | se     | nde | r | derl |   |
|                         |    |        | ssion] | rli | y | ine} |   |
|                         |    |        | {.unde | ne} | e |      |   |
|                         |    |        | rline} |     | a |      |   |
|                         |    |        |        |     | r |      |   |
|                         |    |        |        |     | ] |      |   |
|                         |    |        |        |     | { |      |   |
|                         |    |        |        |     | . |      |   |
|                         |    |        |        |     | u |      |   |
|                         |    |        |        |     | n |      |   |
|                         |    |        |        |     | d |      |   |
|                         |    |        |        |     | e |      |   |
|                         |    |        |        |     | r |      |   |
|                         |    |        |        |     | l |      |   |
|                         |    |        |        |     | i |      |   |
|                         |    |        |        |     | n |      |   |
|                         |    |        |        |     | e |      |   |
|                         |    |        |        |     | } |      |   |
+-------------------------+----+--------+--------+-----+---+------+---+
| a\. How to communicate  | ~  | ~1~ IF | ~1~    | ~2~ | ~ | ~4~  |   |
| effectively with staff  | 0~ | YES    |        |     | 3 |      |   |
| or patients of          |    |        |        |     | ~ |      |   |
| different cultures and  |    |        |        |     |   |      |   |
|                         |    |        |        |     |   |      |   |
| languages               |    |        |        |     |   |      |   |
+-------------------------+----+--------+--------+-----+---+------+---+
| b\. How to work with    | ~  | ~1~ IF | ~1~    | ~2~ | ~ | ~4~  |   |
| face-to-face            | 0~ | YES    |        |     | 3 |      |   |
| interpreters and        |    |        |        |     | ~ |      |   |
| telephone language      |    |        |        |     |   |      |   |
| services                |    |        |        |     |   |      |   |
+-------------------------+----+--------+--------+-----+---+------+---+
| c\. Strategies and/or   | ~  | ~1~ IF | ~1~    | ~2~ | ~ | ~4~  |   |
| techniques for          | 0~ | YES    |        |     | 3 |      |   |
| resolving conflicts     |    |        |        |     | ~ |      |   |
| between staff members   |    |        |        |     |   |      |   |
+-------------------------+----+--------+--------+-----+---+------+---+
| d\. Services for        | ~  | ~1~ IF | ~1~    | ~2~ | ~ | ~4~  |   |
| limited English         | 0~ | YES    |        |     | 3 |      |   |
| proficiency individuals |    |        |        |     | ~ |      |   |
| with respect to Title   |    |        |        |     |   |      |   |
| VI of the Civil Rights  |    |        |        |     |   |      |   |
| Act of 1964             |    |        |        |     |   |      |   |
+-------------------------+----+--------+--------+-----+---+------+---+
| e\. Effect of cultural  | ~  | ~1~ IF | ~1~    | ~2~ | ~ | ~4~  |   |
| and/or language         | 0~ | YES    |        |     | 3 |      |   |
| differences on patient  |    |        |        |     | ~ |      |   |
| education, disease      |    |        |        |     |   |      |   |
| prevention, or patient  |    |        |        |     |   |      |   |
| acceptance of treatment |    |        |        |     |   |      |   |
+-------------------------+----+--------+--------+-----+---+------+---+
| f\. How to inform       | ~  | ~1~ IF | ~1~    | ~2~ | ~ | ~4~  |   |
| patients of diverse     | 0~ | YES    |        |     | 3 |      |   |
| cultures about this     |    |        |        |     | ~ |      |   |
| hospital's              |    |        |        |     |   |      |   |
| complaint/grievance     |    |        |        |     |   |      |   |
| procedures              |    |        |        |     |   |      |   |
+-------------------------+----+--------+--------+-----+---+------+---+
| g\. How to apply        | ~  | ~1~ IF | ~1~    | ~2~ | ~ | ~4~  |   |
| information or          | 0~ | YES    |        |     | 3 |      |   |
| knowledge about         |    |        |        |     | ~ |      |   |
| cultural beliefs in     |    |        |        |     |   |      |   |
| day-to-day patient      |    |        |        |     |   |      |   |
| interactions            |    |        |        |     |   |      |   |
+-------------------------+----+--------+--------+-----+---+------+---+
| h\. How to apply        | ~  | ~1~ IF | ~1~    | ~2~ | ~ | ~4~  |   |
| information or          | 0~ | YES    |        |     | 3 |      |   |
| knowledge about diet or |    |        |        |     | ~ |      |   |
| food preferences of     |    |        |        |     |   |      |   |
| different cultures in   |    |        |        |     |   |      |   |
| day-to-day patient      |    |        |        |     |   |      |   |
| interactions            |    |        |        |     |   |      |   |
+-------------------------+----+--------+--------+-----+---+------+---+

27\. Who conducts training on cultural diversity?

> ***(Check All That Apply)***
>
> ~1~ In-house staff
>
> ~2~ Vendor or contract staff
>
> ~3~ Some other arrangement (please specify)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

28\. Does this hospital require that staff that conducts cultural
diversity training have any type of credential or certification?

> ~0~ No
>
> ~1~ Yes (please specify)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

29\. Do representatives from community-based ethnic organizations
participate in the development of training curricula or materials used
in cultural diversity training offered to this hospital's work force?

> ~0~ No
>
> ~1~ Yes

30\. Do representatives from community-based ethnic organizations
deliver any of the cultural diversity training offered to this
hospital's work force?

> ~0~ No
>
> ~1~ Yes

#####  

### **Section G**

### **Personal Information**

The next few questions will help us to better design this survey and to
ensure it goes to the correct hospital representative.

31\. What is your job title at the hospital?

32\. What are your main duties and responsibilities?

33\. Do you have access to the internet while at work?

> ~0~ No
>
> ~1~ Yes

34\. How many years have you been employed at the hospital?

\_\_\_\_\_\_\_ Number of Years

35\. In the future would it be easier to complete a survey like this...

> ~1~ Over the phone
>
> ~2~ Through the internet, or
>
> ~3~ On paper (like this one)?

36\. Did you find any questions or sections hard to complete?

> ~0~ No
>
> ~1~ Yes IF YES, (Please describe)

37\. Did you require any assistance from another department in answering
any of these questions?

> ~0~ No
>
> ~1~ Yes IF YES, Which questions or sections? (Please describe)

38\. What department(s) did you get assistance from?

39\. May we contact you at a later time to ask you some question about
this survey?

> ~0~ No
>
> ~1~ Yes
>
> Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Phone
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Thanks for taking the time to complete this survey. Please use the
postage-paid envelope to return this survey to:

RAND\
Attn: Kelly Sand

1700 Main Street, PO Box 2138

Santa Monica, CA 90407-2138

**Leadership, Climate and Strategies**

***Statement of Confidentiality***

Any information that identifies you or your hospital will be kept
confidential and used only for the purposes of this study. RAND will not
release any information that identifies you without your prior consent,
except as required by law.

If you have questions about this study or your participation, please
call the RAND Survey Coordinator, Kelly Sand, at

1-310-393-0411 ext. 7479.

  -----------------------------------------------------------------------
  **Survey Instructions**

  -----------------------------------------------------------------------

**Your hospital has been selected as a test health care facility to aid
in the design of Cultural Competency Assessment Tool for Hospitals
(CCATH). The Office of Minority Health, a federal agency within the U.S.
Department of Health and Human Services, sponsors this research.**

**You have received this survey booklet because a representative of your
hospital agreed to help us to test the Leadership, Climate and
Strategies Survey. As you fill out the booklet, please keep in mind that
the information you provide will be kept confidential. Below are some
useful instructions.**

a\. Please answer the questions in this survey booklet about the
hospital where you received this survey.

b\. This survey covers several topics related to your role at this
hospital. For a full list of the topics, please see the table of
contents on the following page.

c\. If you are not sure how to answer a question or if your answer does
not fit the choices we have listed, please make a note in the margin or
at the end of the survey. Because we are testing our survey, your
comments will help us to understand where and how we need to make
changes.

d\. Please answer each question, unless you are instructed to skip to a
specific question. When you should skip over a question, you'll see an
instruction that looks like this:

> **Is today Tuesday?**
>
> ~1~ Yes
>
> ~2~ No *If No, Go to Question 1*

a.  If you have any questions or need more information please call the
    RAND Survey Coordinator, Kelly Sand, at

1-310-393-0411 ext 7479.

b.  When you have completed this survey booklet, please use the
    postage-paid envelope to return it to:

RAND

Attn: Kelly Sand

PO Box 2138

Santa Monica, CA 90407-2138

**Table of Contents**

### 

Section A: Strategies 1

Section B: Assessments of Cultural and Linguistic Goals 3

Section C: Community 5

Section D: The Hospital and the Community 8

Section E: Complaint and Grievance Policies 11

Section F: Climate 13

Section G: Personal Information 14

### 

### **Section A**

### **Strategies**

### 

1\. Does this hospital's mission statement include specific language
about cultural diversity?

> ~0~ No
>
> ~1~ Yes

2\. Does this hospital's statement of strategic goals include:

***(Check One Box in Each Row)***

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Specific language about [recruitment]{.underline}  ~0~                ~1~
  of a culturally diverse work force?                                       

  b\. Specific language about [retention]{.underline} of ~0~                ~1~
  a culturally diverse work force?                                          

  c\. Specific language about the provision of           ~0~                ~1~
  culturally appropriate services?                                          
  ------------------------------------------------------ ------------------ -------------------

3\. Does this hospital's operational plan include:

***(Check One Box in Each Row)***

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Specific language about [recruitment]{.underline}  ~0~                ~1~
  of a culturally diverse work force?                                       

  b\. Specific language about [retention]{.underline} of ~0~                ~1~
  a culturally diverse work force?                                          

  c\. Specific language about the provision of           ~0~                ~1~
  culturally appropriate services?                                          
  ------------------------------------------------------ ------------------ -------------------

4\. Is there a person, office or committee who has dedicated
responsibility for promoting this hospital's cultural diversity goals?

> ~0~ No IF NO, Go to Question 6
>
> ~1~ Yes

5\. Who has dedicated responsibility for promoting this hospital's
cultural diversity goals?

+--------------------------+------+---------+-------+-------+-------+
|                          |      |         | *     |       |       |
|                          |      |         | Which |       |       |
|                          |      |         | of    |       |       |
|                          |      |         | the   |       |       |
|                          |      |         | foll  |       |       |
|                          |      |         | owing |       |       |
|                          |      |         | does  |       |       |
|                          |      |         | this* |       |       |
|                          |      |         |       |       |       |
|                          |      |         | *p    |       |       |
|                          |      |         | erson |       |       |
|                          |      |         | or    |       |       |
|                          |      |         | group |       |       |
|                          |      |         | r     |       |       |
|                          |      |         | eport |       |       |
|                          |      |         | to    |       |       |
|                          |      |         | about |       |       |
|                          |      |         | cul   |       |       |
|                          |      |         | tural |       |       |
|                          |      |         | [dive |       |       |
|                          |      |         | rsity |       |       |
|                          |      |         | goals |       |       |
|                          |      |         | ?]{.u |       |       |
|                          |      |         | nderl |       |       |
|                          |      |         | ine}* |       |       |
+--------------------------+------+---------+-------+-------+-------+
|                          | [No] | [Ye     | [C    | S     | Human |
|                          | {.un | s]{.und | EO]{. | enior | Reso  |
|                          | derl | erline} | under | [     | urces |
|                          | ine} |         | line} | Manag | Dir   |
|                          |      |         |       | er]{. | ector |
|                          |      |         |       | under | or    |
|                          |      |         |       | line} | [     |
|                          |      |         |       |       | Manag |
|                          |      |         |       |       | er]{. |
|                          |      |         |       |       | under |
|                          |      |         |       |       | line} |
+--------------------------+------+---------+-------+-------+-------+
| a\. Designated person    | ~0~  | ~1~ IF  | ~1~   | ~2~   | ~3~   |
|                          |      | YES     |       |       |       |
+--------------------------+------+---------+-------+-------+-------+
| b\. Designated           | ~0~  | ~1~ IF  | ~1~   | ~2~   | ~3~   |
| department or office     |      | YES     |       |       |       |
+--------------------------+------+---------+-------+-------+-------+
| c\. Committee or task    | ~0~  | ~1~ IF  | ~1~   | ~2~   | ~3~   |
| force                    |      | YES     |       |       |       |
+--------------------------+------+---------+-------+-------+-------+

6\. Does this hospital's operating budget include any dedicated line
items to support activities to meet its cultural diversity goals?

> ~0~ No
>
> ~1~ Yes

### **Section B**

### **Assessments of Cultural and Linguistic Goals**

7\. During the strategic planning process, did this hospital conduct an
organizational assessment to identify how well this organization met
current cultural diversity goals?

> ~0~ No
>
> ~1~ Yes

8\. Does this hospital conduct organizational assessments to evaluate
the effectiveness of the following in meeting the cultural and
linguistic needs of the community?

+-----------------------+-----+--------+------+------+------+------+
|                       |     |        | *    |      |      |      |
|                       |     |        | [How |      |      |      |
|                       |     |        | o    |      |      |      |
|                       |     |        | ften |      |      |      |
|                       |     |        | is   |      |      |      |
|                       |     |        | the  |      |      |      |
|                       |     |        | as   |      |      |      |
|                       |     |        | sess |      |      |      |
|                       |     |        | ment |      |      |      |
|                       |     |        | cond |      |      |      |
|                       |     |        | ucte |      |      |      |
|                       |     |        | d?]{ |      |      |      |
|                       |     |        | .und |      |      |      |
|                       |     |        | erli |      |      |      |
|                       |     |        | ne}* |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
|                       | [   | [Yes]  | Less | Once | T    | More |
|                       | No] | {.unde | Than | Per  | wice | Than |
|                       | {.u | rline} |      |      | Per  |      |
|                       | nde |        | Once | [Y   |      | T    |
|                       | rli |        | Per  | ear] | [Y   | wice |
|                       | ne} |        |      | {.un | ear] | Per  |
|                       |     |        | [Y   | derl | {.un |      |
|                       |     |        | ear] | ine} | derl | [Y   |
|                       |     |        | {.un |      | ine} | ear] |
|                       |     |        | derl |      |      | {.un |
|                       |     |        | ine} |      |      | derl |
|                       |     |        |      |      |      | ine} |
+-----------------------+-----+--------+------+------+------+------+
| a\. Management or     | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| governance system     |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| b\. In-patient care   | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| delivery system       |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| c\. Customer          | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| relations system      |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| d\. Existing          | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| relationships with    |     | YES    |      |      |      |      |
| community-based       |     |        |      |      |      |      |
| ethnic organizations  |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+

9\. Does the hospital conduct organizational assessments to evaluate the
effectiveness of the following in meeting its [workforce]{.underline}
diversity goals?

+-----------------------+-----+--------+------+------+------+------+
|                       |     |        | *    |      |      |      |
|                       |     |        | [How |      |      |      |
|                       |     |        | o    |      |      |      |
|                       |     |        | ften |      |      |      |
|                       |     |        | is   |      |      |      |
|                       |     |        | the  |      |      |      |
|                       |     |        | as   |      |      |      |
|                       |     |        | sess |      |      |      |
|                       |     |        | ment |      |      |      |
|                       |     |        | cond |      |      |      |
|                       |     |        | ucte |      |      |      |
|                       |     |        | d?]{ |      |      |      |
|                       |     |        | .und |      |      |      |
|                       |     |        | erli |      |      |      |
|                       |     |        | ne}* |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
|                       | [   | [Yes]  | Less | Once | T    | More |
|                       | No] | {.unde | Than | Per  | wice | Than |
|                       | {.u | rline} |      |      | Per  |      |
|                       | nde |        | Once | [Y   |      | T    |
|                       | rli |        | Per  | ear] | [Y   | wice |
|                       | ne} |        |      | {.un | ear] | Per  |
|                       |     |        | [Y   | derl | {.un |      |
|                       |     |        | ear] | ine} | derl | [Y   |
|                       |     |        | {.un |      | ine} | ear] |
|                       |     |        | derl |      |      | {.un |
|                       |     |        | ine} |      |      | derl |
|                       |     |        |      |      |      | ine} |
+-----------------------+-----+--------+------+------+------+------+
| a\. Recruitment       | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| practices             |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| b\. Organizational    | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| climate               |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| c\. Training and      | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| development           |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| d\. Performance       | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| appraisal             |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| e\. Compensation      | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
|                       |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| f\. Benefits          | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
|                       |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+

10\. Are the following assessments conducted as part of this hospital's
Quality Improvement activities?

+-----------------------+-----+--------+------+------+------+------+
|                       |     |        | *    |      |      |      |
|                       |     |        | [How |      |      |      |
|                       |     |        | o    |      |      |      |
|                       |     |        | ften |      |      |      |
|                       |     |        | is   |      |      |      |
|                       |     |        | it   |      |      |      |
|                       |     |        | ass  |      |      |      |
|                       |     |        | esse |      |      |      |
|                       |     |        | d?]{ |      |      |      |
|                       |     |        | .und |      |      |      |
|                       |     |        | erli |      |      |      |
|                       |     |        | ne}* |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
|                       | [   | [Yes]  | Less | Once | T    | More |
|                       | No] | {.unde | Than | Per  | wice | Than |
|                       | {.u | rline} |      |      | Per  |      |
|                       | nde |        | Once | [Y   |      | T    |
|                       | rli |        | Per  | ear] | [Y   | wice |
|                       | ne} |        |      | {.un | ear] | Per  |
|                       |     |        | [Y   | derl | {.un |      |
|                       |     |        | ear] | ine} | derl | [Y   |
|                       |     |        | {.un |      | ine} | ear] |
|                       |     |        | derl |      |      | {.un |
|                       |     |        | ine} |      |      | derl |
|                       |     |        |      |      |      | ine} |
+-----------------------+-----+--------+------+------+------+------+
| a\. Accessibility of  | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| interpreter services  |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| b\. Racial/ethnic     | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| differences in        |     | YES    |      |      |      |      |
| in-patient service    |     |        |      |      |      |      |
| use                   |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| c\. Racial/ethnic     | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| differences in        |     | YES    |      |      |      |      |
| patient assessments   |     |        |      |      |      |      |
| of care               |     |        |      |      |      |      |
| (satisfaction)        |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+

### **Section C**

### **Community**

11\. Does this hospital collect any of the following data on the
[population residing in the service area]{.underline}?

+-----------------------+-----+--------+------+------+------+------+
|                       |     |        | *    |      |      |      |
|                       |     |        | [How |      |      |      |
|                       |     |        | o    |      |      |      |
|                       |     |        | ften |      |      |      |
|                       |     |        | is   |      |      |      |
|                       |     |        | this |      |      |      |
|                       |     |        | data |      |      |      |
|                       |     |        | coll |      |      |      |
|                       |     |        | ecte |      |      |      |
|                       |     |        | d?]{ |      |      |      |
|                       |     |        | .und |      |      |      |
|                       |     |        | erli |      |      |      |
|                       |     |        | ne}* |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
|                       | [   | [Yes]  | Less | Once | T    | More |
|                       | No] | {.unde | Than | Per  | wice | Than |
|                       | {.u | rline} |      |      | Per  |      |
|                       | nde |        | Once | [Y   |      | T    |
|                       | rli |        | Per  | ear] | [Y   | wice |
|                       | ne} |        |      | {.un | ear] | Per  |
|                       |     |        | [Y   | derl | {.un |      |
|                       |     |        | ear] | ine} | derl | [Y   |
|                       |     |        | {.un |      | ine} | ear] |
|                       |     |        | derl |      |      | {.un |
|                       |     |        | ine} |      |      | derl |
|                       |     |        |      |      |      | ine} |
+-----------------------+-----+--------+------+------+------+------+
| a\. Race/ethnicity    | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
|                       |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| b\. Languages spoken  | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
|                       |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| c\. Income levels     | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
|                       |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| d\. Education levels  | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
|                       |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| e\. Health risks      | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| profile               |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| f\. Health conditions | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| profile               |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| g\. Utilization of    | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| health screening      |     | YES    |      |      |      |      |
| services\             |     |        |      |      |      |      |
| (mammograms, prostate |     |        |      |      |      |      |
| screening exams, PAP  |     |        |      |      |      |      |
| smears)               |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+

12\. Which of the following methods are used by the hospital to identify
the cultural and linguistic needs of the population served?

+-----------+---+--------+-----+-----+------+-----+--------+--------+
|           |   |        | *   |     |      |     |        |        |
|           |   |        | [In |     |      |     |        |        |
|           |   |        | w   |     |      |     |        |        |
|           |   |        | hat |     |      |     |        |        |
|           |   |        | lan |     |      |     |        |        |
|           |   |        | gua |     |      |     |        |        |
|           |   |        | ges |     |      |     |        |        |
|           |   |        | is  |     |      |     |        |        |
|           |   |        | t   |     |      |     |        |        |
|           |   |        | his |     |      |     |        |        |
|           |   |        | t   |     |      |     |        |        |
|           |   |        | ask |     |      |     |        |        |
|           |   |        | con |     |      |     |        |        |
|           |   |        | duc |     |      |     |        |        |
|           |   |        | ted |     |      |     |        |        |
|           |   |        | ?]{ |     |      |     |        |        |
|           |   |        | .un |     |      |     |        |        |
|           |   |        | der |     |      |     |        |        |
|           |   |        | lin |     |      |     |        |        |
|           |   |        | e}* |     |      |     |        |        |
+-----------+---+--------+-----+-----+------+-----+--------+--------+
|           | [ | [Yes]  | [Sp | [Ch | [Vie | [K  | [      | [      |
|           | N | {.unde | ani | ine | tnam | ore | Other] | Othe]{ |
|           | o | rline} | sh] | se] | ese] | an] | {.unde | .under |
|           | ] |        | {.u | {.u | {.un | {.u | rline} | line}r |
|           | { |        | nde | nde | derl | nde |        |        |
|           | . |        | rli | rli | ine} | rli |        |        |
|           | u |        | ne} | ne} |      | ne} |        |        |
|           | n |        |     |     |      |     |        |        |
|           | d |        |     |     |      |     |        |        |
|           | e |        |     |     |      |     |        |        |
|           | r |        |     |     |      |     |        |        |
|           | l |        |     |     |      |     |        |        |
|           | i |        |     |     |      |     |        |        |
|           | n |        |     |     |      |     |        |        |
|           | e |        |     |     |      |     |        |        |
|           | } |        |     |     |      |     |        |        |
+-----------+---+--------+-----+-----+------+-----+--------+--------+
| a\. Focus | ~ | ~1~ IF | ~1~ | ~2~ | ~3~  | ~4~ | ~5~    | ~6~    |
| groups    | 0 | YES    |     |     |      |     | \_     | \_\_   |
| with      | ~ |        |     |     |      |     | \_\_\_ | \_\_\_ |
| community |   |        |     |     |      |     | \_\_\_ |        |
| members   |   |        |     |     |      |     |        |        |
| residing  |   |        |     |     |      |     |        |        |
| in the    |   |        |     |     |      |     |        |        |
| service   |   |        |     |     |      |     |        |        |
| area      |   |        |     |     |      |     |        |        |
+-----------+---+--------+-----+-----+------+-----+--------+--------+
| b\.       | ~ | ~1~ IF | ~1~ | ~2~ | ~3~  | ~4~ | ~5~    | ~6~    |
| In-depth  | 0 | YES    |     |     |      |     | \_\_   | \_\_   |
| personal  | ~ |        |     |     |      |     | \_\_\_ | \_\_\_ |
| i         |   |        |     |     |      |     |        |        |
| nterviews |   |        |     |     |      |     |        |        |
| (face to  |   |        |     |     |      |     |        |        |
| face or   |   |        |     |     |      |     |        |        |
| t         |   |        |     |     |      |     |        |        |
| elephone) |   |        |     |     |      |     |        |        |
| with      |   |        |     |     |      |     |        |        |
| community |   |        |     |     |      |     |        |        |
| members   |   |        |     |     |      |     |        |        |
| residing  |   |        |     |     |      |     |        |        |
| in the    |   |        |     |     |      |     |        |        |
| service   |   |        |     |     |      |     |        |        |
| area      |   |        |     |     |      |     |        |        |
+-----------+---+--------+-----+-----+------+-----+--------+--------+
| c\. Focus | ~ | ~1~ IF | ~1~ | ~2~ | ~3~  | ~4~ | ~5~    | ~6~    |
| groups    | 0 | YES    |     |     |      |     | \_\_   | \_\_   |
| with      | ~ |        |     |     |      |     | \_\_\_ | \_\_\_ |
| in        |   |        |     |     |      |     |        |        |
| dividuals |   |        |     |     |      |     |        |        |
| who have  |   |        |     |     |      |     |        |        |
| received  |   |        |     |     |      |     |        |        |
|           |   |        |     |     |      |     |        |        |
| i         |   |        |     |     |      |     |        |        |
| n-patient |   |        |     |     |      |     |        |        |
| services  |   |        |     |     |      |     |        |        |
+-----------+---+--------+-----+-----+------+-----+--------+--------+
| d\.       | ~ | ~1~ IF | ~1~ | ~2~ | ~3~  | ~4~ | ~5~    | ~6~    |
| Sat       | 0 | YES    |     |     |      |     | \_\_   | \_\_   |
| isfaction | ~ |        |     |     |      |     | \_\_\_ | \_\_\_ |
| surveys   |   |        |     |     |      |     |        |        |
| of        |   |        |     |     |      |     |        |        |
| in        |   |        |     |     |      |     |        |        |
| dividuals |   |        |     |     |      |     |        |        |
| who have  |   |        |     |     |      |     |        |        |
| received  |   |        |     |     |      |     |        |        |
|           |   |        |     |     |      |     |        |        |
| i         |   |        |     |     |      |     |        |        |
| n-patient |   |        |     |     |      |     |        |        |
| services  |   |        |     |     |      |     |        |        |
+-----------+---+--------+-----+-----+------+-----+--------+--------+
| e\.       | ~ | ~1~ IF | ~1~ | ~2~ | ~3~  | ~4~ | ~5~    | ~6~    |
| In-depth  | 0 | YES    |     |     |      |     | \_\_   | \_\_   |
| personal  | ~ |        |     |     |      |     | \_\_\_ | \_\_\_ |
| i         |   |        |     |     |      |     |        |        |
| nterviews |   |        |     |     |      |     |        |        |
| (face to  |   |        |     |     |      |     |        |        |
| face or   |   |        |     |     |      |     |        |        |
| t         |   |        |     |     |      |     |        |        |
| elephone) |   |        |     |     |      |     |        |        |
| with      |   |        |     |     |      |     |        |        |
| in        |   |        |     |     |      |     |        |        |
| dividuals |   |        |     |     |      |     |        |        |
| who have  |   |        |     |     |      |     |        |        |
| received  |   |        |     |     |      |     |        |        |
| i         |   |        |     |     |      |     |        |        |
| n-patient |   |        |     |     |      |     |        |        |
| services? |   |        |     |     |      |     |        |        |
+-----------+---+--------+-----+-----+------+-----+--------+--------+

13\. Does this hospital use the following sources of data in service
planning?

+-----------------------+-----+--------+------+------+------+------+
|                       |     |        | *    |      |      |      |
|                       |     |        | [How |      |      |      |
|                       |     |        | o    |      |      |      |
|                       |     |        | ften |      |      |      |
|                       |     |        | is   |      |      |      |
|                       |     |        | this |      |      |      |
|                       |     |        | data |      |      |      |
|                       |     |        | comp |      |      |      |
|                       |     |        | iled |      |      |      |
|                       |     |        | or   |      |      |      |
|                       |     |        | coll |      |      |      |
|                       |     |        | ecte |      |      |      |
|                       |     |        | d?]{ |      |      |      |
|                       |     |        | .und |      |      |      |
|                       |     |        | erli |      |      |      |
|                       |     |        | ne}* |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
|                       | [   | [Yes]  | Less | Once | T    | More |
|                       | No] | {.unde | Than | Per  | wice | Than |
|                       | {.u | rline} |      |      | Per  |      |
|                       | nde |        | Once | [Y   |      | T    |
|                       | rli |        | Per  | ear] | [Y   | wice |
|                       | ne} |        |      | {.un | ear] | Per  |
|                       |     |        | [Y   | derl | {.un |      |
|                       |     |        | ear] | ine} | derl | [Y   |
|                       |     |        | {.un |      | ine} | ear] |
|                       |     |        | derl |      |      | {.un |
|                       |     |        | ine} |      |      | derl |
|                       |     |        |      |      |      | ine} |
+-----------------------+-----+--------+------+------+------+------+
| a\. County or state   | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| health statistics     |     | YES    |      |      |      |      |
| reports               |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| b\. Other government  | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| health data           |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| c\. Census data       | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| covering the service  |     | YES    |      |      |      |      |
| area                  |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| d\. Community health  | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| assessments           |     | YES    |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+

14\. Which of the following activities is informed by the
community-level data collected by this hospital?

+-----------------------+-----+--------+------+------+------+------+
|                       |     |        | *    |      |      |      |
|                       |     |        | [How |      |      |      |
|                       |     |        | o    |      |      |      |
|                       |     |        | ften |      |      |      |
|                       |     |        | do   |      |      |      |
|                       |     |        | t    |      |      |      |
|                       |     |        | hese |      |      |      |
|                       |     |        | ac   |      |      |      |
|                       |     |        | tivi |      |      |      |
|                       |     |        | ties |      |      |      |
|                       |     |        | occu |      |      |      |
|                       |     |        | r?]{ |      |      |      |
|                       |     |        | .und |      |      |      |
|                       |     |        | erli |      |      |      |
|                       |     |        | ne}* |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
|                       | [   | [Yes]  | Less | Once | T    | More |
|                       | No] | {.unde | Than | Per  | wice | Than |
|                       | {.u | rline} |      |      | Per  |      |
|                       | nde |        | Once | [Y   |      | T    |
|                       | rli |        | Per  | ear] | [Y   | wice |
|                       | ne} |        |      | {.un | ear] | Per  |
|                       |     |        | [Y   | derl | {.un |      |
|                       |     |        | ear] | ine} | derl | [Y   |
|                       |     |        | {.un |      | ine} | ear] |
|                       |     |        | derl |      |      | {.un |
|                       |     |        | ine} |      |      | derl |
|                       |     |        |      |      |      | ine} |
+-----------------------+-----+--------+------+------+------+------+
| a\. Development of a  | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| community health      |     | YES    |      |      |      |      |
| needs assessment?     |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| b\. Planning or       | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| implementation of new |     | YES    |      |      |      |      |
| services              |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| c\. Evaluation of     | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| access to health care |     | YES    |      |      |      |      |
| services for the      |     |        |      |      |      |      |
| population residing   |     |        |      |      |      |      |
| in the service area   |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| d\. Evaluation of     | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| utilization of health |     | YES    |      |      |      |      |
| care services by the  |     |        |      |      |      |      |
| population residing   |     |        |      |      |      |      |
| in the service area   |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+

### **Section D**

### **The Hospital and the Community**

15\. Does this hospital have a formal or working relationship [in the
hospital's service area]{.underline} with:

  ------------------------ ------------------ ------------------- ----------------------------- --------------------------- --------------------------- --------------------------
                                                                  *[What is the goal of this                                                            
                                                                  relationship?]{.underline}*                                                           

                           [No]{.underline}   [Yes]{.underline}   For Service Delivery to       To Provide Service          As a Partner in Community   To Develop Community
                                                                  Culturally Diverse            Referrals to Culturally     Outreach to Culturally      Profiles or Needs
                                                                  [Populations]{.underline}     Diverse                     Diverse                     [Assessmen]{.underline}t
                                                                                                [Populations]{.underline}   [Populations]{.underline}   

  a\. Community health     ~0~                ~1~ IF YES          ~1~                           ~2~                         ~3~                         ~4~
  partnerships and/or                                                                                                                                   
  collaborative?                                                                                                                                        

  b\. County health        ~0~                ~1~ IF YES          ~1~                           ~2~                         ~3~                         ~4~
  clinics                                                                                                                                               

  c\.                      ~0~                ~1~ IF YES          ~1~                           ~2~                         ~3~                         ~4~
  University-affiliated                                                                                                                                 
  health clinics                                                                                                                                        

  d\. Independent health   ~0~                ~1~ IF YES          ~1~                           ~2~                         ~3~                         ~4~
  centers or clinics                                                                                                                                    

  e\. Other hospitals      ~0~                ~1~ IF YES          ~1~                           ~2~                         ~3~                         ~4~

  f\. Cultural or ethnic   ~0~                ~1~ IF YES          ~1~                           ~2~                         ~3~                         ~4~
  organizations                                                                                                                                         

  g\. Religious            ~0~                ~1~ IF YES          ~1~                           ~2~                         ~3~                         ~4~
  organizations                                                                                                                                         

  h\. Educational          ~0~                ~1~ IF YES          ~1~                           ~2~                         ~3~                         ~4~
  institutions                                                                                                                                          

  i\. Migrant and rural    ~0~                ~1~ IF YES          ~1~                           ~2~                         ~3~                         ~4~
  health services                                                                                                                                       

  j\. Other kinds of       ~0~                ~1~ IF YES          ~1~                           ~2~                         ~3~                         ~4~
  community-based                                                                                                                                       
  organizations                                                                                                                                         
  ------------------------ ------------------ ------------------- ----------------------------- --------------------------- --------------------------- --------------------------

16\. Does this hospital routinely report to the public information about
its performance in meeting the cultural and linguistics needs of the
service area?

> ~0~ No IF NO, Go to Question 19
>
> ~1~ Yes

17\. Which of the following types of information does this hospital
routinely report to the public?

+-----------------------+-----+--------+------+------+------+------+
|                       |     |        | *    |      |      |      |
|                       |     |        | [How |      |      |      |
|                       |     |        | o    |      |      |      |
|                       |     |        | ften |      |      |      |
|                       |     |        | is   |      |      |      |
|                       |     |        | the  |      |      |      |
|                       |     |        | pu   |      |      |      |
|                       |     |        | blic |      |      |      |
|                       |     |        | re   |      |      |      |
|                       |     |        | port |      |      |      |
|                       |     |        | up   |      |      |      |
|                       |     |        | date |      |      |      |
|                       |     |        | d?]{ |      |      |      |
|                       |     |        | .und |      |      |      |
|                       |     |        | erli |      |      |      |
|                       |     |        | ne}* |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
|                       | [   | [Yes]  | Less | Once | T    | More |
|                       | No] | {.unde | Than | Per  | wice | Than |
|                       | {.u | rline} |      |      | Per  |      |
|                       | nde |        | Once | [Y   |      | T    |
|                       | rli |        | Per  | ear] | [Y   | wice |
|                       | ne} |        |      | {.un | ear] | Per  |
|                       |     |        | [Y   | derl | {.un |      |
|                       |     |        | ear] | ine} | derl | [Y   |
|                       |     |        | {.un |      | ine} | ear] |
|                       |     |        | derl |      |      | {.un |
|                       |     |        | ine} |      |      | derl |
|                       |     |        |      |      |      | ine} |
+-----------------------+-----+--------+------+------+------+------+
| a\. Statistics on     | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| in                    |     | YES    |      |      |      |      |
| terpreter/translator\ |     |        |      |      |      |      |
| service use?          |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| b\. Programs to       | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| address the cultural  |     | YES    |      |      |      |      |
| or language needs of  |     |        |      |      |      |      |
| the population        |     |        |      |      |      |      |
| residing in this      |     |        |      |      |      |      |
| hospital's service    |     |        |      |      |      |      |
|                       |     |        |      |      |      |      |
| area                  |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| c\. Improvement in    | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| in-patient outcomes   |     | YES    |      |      |      |      |
| for specific racial   |     |        |      |      |      |      |
| or ethnic groups      |     |        |      |      |      |      |
| served by this        |     |        |      |      |      |      |
| hospital              |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| d\. Statistics on     | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| staff participating   |     | YES    |      |      |      |      |
| in cultural diversity |     |        |      |      |      |      |
| training programs     |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| e\. Other information | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| related to            |     | YES    |      |      |      |      |
| implementation\       |     |        |      |      |      |      |
| of the CLAS standards |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+

18\. Which of the following does this hospital use to communicate about
the hospital's performance in meeting the cultural and linguistic needs
of the service area?

<table>
<colgroup>
<col style="width: 16%" />
<col style="width: 4%" />
<col style="width: 12%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 10%" />
<col style="width: 7%" />
<col style="width: 12%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td colspan="7"><em><u>In what languages?</u></em></td>
</tr>
<tr class="even">
<td></td>
<td><u>No</u></td>
<td><u>Yes</u></td>
<td><u>English</u></td>
<td><u>Spanish</u></td>
<td><u>Chinese</u></td>
<td><u>Vietnamese</u></td>
<td><u>Korean</u></td>
<td><u>Othe</u>r</td>
<td><u>Other</u></td>
</tr>
<tr class="odd">
<td>a. Community newsletter</td>
<td><sub>0</sub></td>
<td><sub>1</sub> IF YES</td>
<td><sub>1</sub></td>
<td><sub>2</sub></td>
<td><sub>3</sub></td>
<td><sub>4</sub></td>
<td><sub>5</sub></td>
<td><sub>6</sub> ______</td>
<td><sub>7</sub> ______</td>
</tr>
<tr class="even">
<td>b. Radio advertisements</td>
<td><sub>0</sub></td>
<td><sub>1</sub> IF YES</td>
<td><sub>1</sub></td>
<td><sub>2</sub></td>
<td><sub>3</sub></td>
<td><sub>4</sub></td>
<td><sub>5</sub></td>
<td><sub>6</sub> ______</td>
<td><sub>7</sub> ______</td>
</tr>
<tr class="odd">
<td>c. Television advertisements</td>
<td><sub>0</sub></td>
<td><sub>1</sub> IF YES</td>
<td><sub>1</sub></td>
<td><sub>2</sub></td>
<td><sub>3</sub></td>
<td><sub>4</sub></td>
<td><sub>5</sub></td>
<td><sub>6</sub> ______</td>
<td><sub>7</sub> ______</td>
</tr>
<tr class="even">
<td>d. Advertisements in the newspaper or other print media</td>
<td><sub>0</sub></td>
<td><sub>1</sub> IF YES</td>
<td><sub>1</sub></td>
<td><sub>2</sub></td>
<td><sub>3</sub></td>
<td><sub>4</sub></td>
<td><sub>5</sub></td>
<td><sub>6</sub> ______</td>
<td><sub>7</sub> ______</td>
</tr>
<tr class="odd">
<td>e. Newspaper articles or interviews with hospital staff</td>
<td><sub>0</sub></td>
<td><sub>1</sub> IF YES</td>
<td><sub>1</sub></td>
<td><sub>2</sub></td>
<td><sub>3</sub></td>
<td><sub>4</sub></td>
<td><sub>5</sub></td>
<td><sub>6</sub> ______</td>
<td><sub>7</sub> ______</td>
</tr>
<tr class="even">
<td><p>f. Hospital web</p>
<p>site</p></td>
<td><sub>0</sub></td>
<td><sub>1</sub> IF YES</td>
<td><sub>1</sub></td>
<td><sub>2</sub></td>
<td><sub>3</sub></td>
<td><sub>4</sub></td>
<td><sub>5</sub></td>
<td><sub>6</sub> ______</td>
<td><sub>7</sub> ______</td>
</tr>
<tr class="odd">
<td>g. Community meetings</td>
<td><sub>0</sub></td>
<td><sub>1</sub> IF YES</td>
<td><sub>1</sub></td>
<td><sub>2</sub></td>
<td><sub>3</sub></td>
<td><sub>4</sub></td>
<td><sub>5</sub></td>
<td><sub>6</sub> ______</td>
<td><sub>7</sub> ______</td>
</tr>
<tr class="even">
<td>h. Marketing literature</td>
<td><sub>0</sub></td>
<td><sub>1</sub> IF YES</td>
<td><sub>1</sub></td>
<td><sub>2</sub></td>
<td><sub>3</sub></td>
<td><sub>4</sub></td>
<td><sub>5</sub></td>
<td><sub>6</sub> ______</td>
<td><sub>7</sub> ______</td>
</tr>
</tbody>
</table>

### **Section E**

### **Complaint and Grievance Policies**

19\. Does this hospital:

+-----------------------+-----+--------+------+------+------+------+
|                       |     |        | *    |      |      |      |
|                       |     |        | [How |      |      |      |
|                       |     |        | o    |      |      |      |
|                       |     |        | ften |      |      |      |
|                       |     |        | do   |      |      |      |
|                       |     |        | t    |      |      |      |
|                       |     |        | hese |      |      |      |
|                       |     |        | ac   |      |      |      |
|                       |     |        | tivi |      |      |      |
|                       |     |        | ties |      |      |      |
|                       |     |        | occu |      |      |      |
|                       |     |        | r?]{ |      |      |      |
|                       |     |        | .und |      |      |      |
|                       |     |        | erli |      |      |      |
|                       |     |        | ne}* |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
|                       | [   | [Yes]  | Less | Once | T    | More |
|                       | No] | {.unde | Than | Per  | wice | Than |
|                       | {.u | rline} |      |      | Per  |      |
|                       | nde |        | Once | [Y   |      | T    |
|                       | rli |        | Per  | ear] | [Y   | wice |
|                       | ne} |        |      | {.un | ear] | Per  |
|                       |     |        | [Y   | derl | {.un |      |
|                       |     |        | ear] | ine} | derl | [Y   |
|                       |     |        | {.un |      | ine} | ear] |
|                       |     |        | derl |      |      | {.un |
|                       |     |        | ine} |      |      | derl |
|                       |     |        |      |      |      | ine} |
+-----------------------+-----+--------+------+------+------+------+
| a\. Use staff peer    | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| observations to       |     | YES    |      |      |      |      |
| collect information   |     |        |      |      |      |      |
| on patient complaints |     |        |      |      |      |      |
| or grievances?        |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| b\. Use medical chart | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| review to collect     |     | YES    |      |      |      |      |
| information on        |     |        |      |      |      |      |
| patient complaints or |     |        |      |      |      |      |
| grievances?           |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+

20\. Do the staff involved in the formal complaint and grievance
process:

+-----------------------+-----+--------+------+------+------+------+
|                       |     |        | *    |      |      |      |
|                       |     |        | [How |      |      |      |
|                       |     |        | o    |      |      |      |
|                       |     |        | ften |      |      |      |
|                       |     |        | does |      |      |      |
|                       |     |        | trai |      |      |      |
|                       |     |        | ning |      |      |      |
|                       |     |        | occu |      |      |      |
|                       |     |        | r?]{ |      |      |      |
|                       |     |        | .und |      |      |      |
|                       |     |        | erli |      |      |      |
|                       |     |        | ne}* |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
|                       | [   | [Yes]  | Less | Once | T    | More |
|                       | No] | {.unde | Than | Per  | wice | Than |
|                       | {.u | rline} |      |      | Per  |      |
|                       | nde |        | Once | [Y   |      | T    |
|                       | rli |        | Per  | ear] | [Y   | wice |
|                       | ne} |        |      | {.un | ear] | Per  |
|                       |     |        | [Y   | derl | {.un |      |
|                       |     |        | ear] | ine} | derl | [Y   |
|                       |     |        | {.un |      | ine} | ear] |
|                       |     |        | derl |      |      | {.un |
|                       |     |        | ine} |      |      | derl |
|                       |     |        |      |      |      | ine} |
+-----------------------+-----+--------+------+------+------+------+
| a\. Receive formal    | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| training in conflict  |     | YES    |      |      |      |      |
| resolution?           |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+
| b\. Receive formal    | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~  | ~4~  |
| training about        |     | YES    |      |      |      |      |
| cultural or language  |     |        |      |      |      |      |
| differences?          |     |        |      |      |      |      |
+-----------------------+-----+--------+------+------+------+------+

21\. Does this hospital monitor or track formal complaints or grievances
that are related to culture or language?

> ~0~ No IF NO, Go to Question 23
>
> ~1~ Yes

22\. How is the data from monitoring or tracking used?

> ***(Check All That Apply)***
>
> ~1~ To reduce the number of complaints based on culture or language
>
> ~2~ To improve consumer awareness of complaint procedures
>
> ~3~ Other (please specify):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

23\. Does this hospital:

  -------------- ------------------ ------------------- ----------------------- ----------------------- -------------------------- ---------------------- --------------------- ---------------------
                 [No]{.underline}   [Yes]{.underline}   [Spanish]{.underline}   [Chinese]{.underline}   [Vietnamese]{.underline}   [Korean]{.underline}   [Other]{.underline}   [Othe]{.underline}r

  a\. Routinely  ~0~                ~1~ IF YES          ~1~                     ~2~                     ~3~                        ~4~                    ~5~ \_\_\_\_\_\_      ~6~ \_\_\_\_\_\_
  provide all                                                                                                                                                                   
  patients with                                                                                                                                                                 
  written                                                                                                                                                                       
  instructions                                                                                                                                                                  
  for filing a                                                                                                                                                                  
  complaint or                                                                                                                                                                  
  grievance?                                                                                                                                                                    

  b\. Have a     ~0~                ~1~ IF YES          ~1~                     ~2~                     ~3~                        ~4~                    ~5~ \_\_\_\_\_\_      ~6~ \_\_\_\_\_\_
  patient                                                                                                                                                                       
  ombudsman                                                                                                                                                                     
  office?                                                                                                                                                                       

  c\. Use focus  ~0~                ~1~ IF YES          ~1~                     ~2~                     ~3~                        ~4~                    ~5~ \_\_\_\_\_\_      ~6~ \_\_\_\_\_\_
  groups to                                                                                                                                                                     
  collect                                                                                                                                                                       
  information on                                                                                                                                                                
  patient                                                                                                                                                                       
  complaints or                                                                                                                                                                 
  grievances?                                                                                                                                                                   

  d\. Use        ~0~                ~1~ IF YES          ~1~                     ~2~                     ~3~                        ~4~                    ~5~ \_\_\_\_\_\_      ~6~ \_\_\_\_\_\_
  patient                                                                                                                                                                       
  interviews to                                                                                                                                                                 
  collect                                                                                                                                                                       
  information on                                                                                                                                                                
  patient                                                                                                                                                                       
  complaints or                                                                                                                                                                 
  grievances?                                                                                                                                                                   
  -------------- ------------------ ------------------- ----------------------- ----------------------- -------------------------- ---------------------- --------------------- ---------------------

### **Section F**

### **Climate**

24\. How true or false are the following statements about this hospital?

***(Check One Box on Each Line)***

+---------------------------------------+------+------+------+------+
|                                       | De   | Some | Some | De   |
|                                       | fini | what | what | fini |
|                                       | tely |      |      | tely |
|                                       |      | [Fa  | [T   |      |
|                                       | [Fa  | lse] | rue] | [T   |
|                                       | lse] | {.un | {.un | rue] |
|                                       | {.un | derl | derl | {.un |
|                                       | derl | ine} | ine} | derl |
|                                       | ine} |      |      | ine} |
+---------------------------------------+------+------+------+------+
| a\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| speak with enthusiasm\                |      |      |      |      |
| and commitment to the organization's  |      |      |      |      |
| agenda for a culturally\              |      |      |      |      |
| diverse work force                    |      |      |      |      |
+---------------------------------------+------+------+------+------+
| b\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| promote a culturally diverse work     |      |      |      |      |
| force as a competitive advantage      |      |      |      |      |
+---------------------------------------+------+------+------+------+
| c\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| promote culturally competent care as  |      |      |      |      |
| a competitive advantage               |      |      |      |      |
+---------------------------------------+------+------+------+------+
| d\. This hospital not only tolerates  | ~1~  | ~2~  | ~3~  | ~4~  |
| but also values differences people    |      |      |      |      |
| bring to the workplace                |      |      |      |      |
+---------------------------------------+------+------+------+------+

### **Section G**

### **Personal Information**

The next few questions will help us to better design this survey and to
ensure it goes to the correct hospital representative.

25\. What is your job title at the hospital?

26\. What are your main duties and responsibilities?

27\. Do you have access to the internet while at work?

> ~0~ No
>
> ~1~ Yes

28\. How many years have you been employed at the hospital?

\_\_\_\_\_\_\_ Number of Years

29\. In the future would it be easier to complete a survey like this...

> ~1~ Over the phone
>
> ~2~ Through the internet, or
>
> ~3~ On paper (like this one)?

30\. Did you find any questions or sections hard to complete?

> ~0~ No
>
> ~1~ Yes IF YES, (Please describe)

31\. Did you require any assistance from another department in answering
any of these questions?

> ~0~ No
>
> ~1~ Yes IF YES, Which questions or sections? (Please describe)

32\. What department(s) did you get assistance from?

33\. May we contact you at a later time to ask you some question about
this survey?

> ~0~ No
>
> ~1~ Yes
>
> Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Phone
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Thanks for taking the time to complete this survey. Please use the
postage-paid envelope to return this survey to:

RAND

Attn: Kelly Sand

1700 Main Street

PO Box 2138

Santa Monica, CA 90407-2138

CULTURAL COMPETENCY ASSESSMENT TOOL FOR HOSPITALS

## 

## 

## Translation and Interpreters

***Statement of Confidentiality***

Any information that identifies you or your hospital will be kept
confidential and used only for the purposes of this study. RAND will not
release any information that identifies you without your prior consent,
except as required by law.

If you have questions about this study or your participation, please
call the RAND Survey Coordinator, Kelly Sand, at

1-310-393-0411 ext 7479.

  -----------------------------------------------------------------------
  **Survey Instructions**

  -----------------------------------------------------------------------

**Your hospital has been selected as a test health care facility to aid
in the design of Cultural Competency Assessment Tool for Hospitals
(CCATH). The Office of Minority Health, a federal agency within the U.S.
Department of Health and Human Services, sponsors this research.**

**You have received this survey booklet because a representative of your
hospital agreed to help us to test the Translation and Interpreters
Survey. As you fill out the booklet, please keep in mind that the
information you provide will be kept confidential. Below are some useful
instructions.**

a.  Please answer the questions in this survey booklet about the
    hospital where you received this survey.

b.  This survey covers several topics related to your role at this
    hospital. For a full list of the topics, please see the table of
    contents on the following page.

c.  If you are not sure how to answer a question or if your answer does
    not fit the choices we have listed, please make a note in the margin
    or at the end of the survey. Because we are testing our survey, your
    comments will help us to understand where and how we need to make
    changes.

d.  Please answer each question, unless you are instructed to skip to a
    specific question. When you should skip over a question, you'll see
    an instruction that looks like this:

> **Is today Tuesday?**
>
> ~1~ Yes
>
> ~2~ No IF NO, Go to Question 1

e.  If you have any questions or need more information please call the
    RAND Survey Coordinator, Kelly Sand, at

1-310-393-0411 ext 7479.

f.  When you have completed this survey booklet, please use the
    postage-paid envelope to return it to:

RAND

Attn: Kelly Sand

1700 Main Street

PO Box 2138

Santa Monica, CA 90407-2138

## 

## Table of Contents

## 

Section A: Patient Interpreters 1

Section B: Advertising Interpreter Services 3

Section C: Hospital Policies and Interpreter Certification 5

Section D: Translation 8

Section E: Climate 11

Section F: Personal Information 12

### 

### **Section A**

### **Patient Interpreters**

## 

This first set of questions are about interpreters. Please note that an
interpreter translates [orally]{.underline} from one language to
another. A translator deals with the translation of
[written]{.underline} materials from the source language into another
language.

1.  Which of the following interpreter services does this hospital
    offer?

*[When are these services available?]{.underline}*

(CHECK ALL THAT APPLY)

  ------------------------ ------------------ ------------------- ------------------- --------------------- -------------------- ----------------------
                           [No]{.underline}   [Yes]{.underline}   [Week               [Week                 Weekend              Weekend
                                                                  Days]{.underline}   Nights]{.underline}   [Days]{.underline}   [Nights]{.underline}

  a\. Bilingual staff as   ~0~                ~1~ IF YES          ~1~                 ~2~                   ~3~                  ~4~
  interpreters                                                                                                                   

  b\. Face-to-face         ~0~                ~1~ IF YES          ~1~                 ~2~                   ~3~                  ~4~
  professional                                                                                                                   
  interpreters                                                                                                                   

  c\. Face-to-face         ~0~                ~1~ IF YES          ~1~                 ~2~                   ~3~                  ~4~
  volunteer interpreters                                                                                                         

  d\. Telephone            ~0~                ~1~ IF YES          ~1~                 ~2~                   ~3~                  ~4~
  interpreters                                                                                                                   
  ------------------------ ------------------ ------------------- ------------------- --------------------- -------------------- ----------------------

2\. In what languages are interpreter services available for
in-patients?

####  [Which services are available?]{.underline}

+-----------------------+-----+--------+------+------+-------+------+
|                       | [   | [Yes]  | B    | Face | Fa    | T    |
|                       | No] | {.unde | ilin | -to- | ce-to | elep |
|                       | {.u | rline} | gual | Face | -Face | hone |
|                       | nde |        | [St  | [P   |       | [    |
|                       | rli |        | aff] | rofe | [Vo   | Inte |
|                       | ne} |        | {.un | ssio | lunte | rpre |
|                       |     |        | derl | nal] | er]{. | ter] |
|                       |     |        | ine} | {.un | under | {.un |
|                       |     |        |      | derl | line} | derl |
|                       |     |        |      | ine} |       | ine} |
+-----------------------+-----+--------+------+------+-------+------+
| a\. Spanish           | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~   | ~4~  |
|                       |     | YES    |      |      |       |      |
+-----------------------+-----+--------+------+------+-------+------+
| b\. Chinese           | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~   | ~4~  |
|                       |     | YES    |      |      |       |      |
+-----------------------+-----+--------+------+------+-------+------+
| c\. Vietnamese        | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~   | ~4~  |
|                       |     | YES    |      |      |       |      |
+-----------------------+-----+--------+------+------+-------+------+
| d\. Korean            | ~0~ | ~1~ IF | ~1~  | ~2~  | ~3~   | ~4~  |
|                       |     | YES    |      |      |       |      |
+-----------------------+-----+--------+------+------+-------+------+
| e\. Other: (please    |     |        | ~1~  | ~2~  | ~3~   | ~4~  |
| specify)\_\_\_\_\     |     |        |      |      |       |      |
| _\_\_\_\_\_\_\_\_\_\_ |     |        |      |      |       |      |
+-----------------------+-----+--------+------+------+-------+------+
| f\. Other: (please    |     |        | ~1~  | ~2~  | ~3~   | ~4~  |
| specify)\_\_\_\_\     |     |        |      |      |       |      |
| _\_\_\_\_\_\_\_\_\_\_ |     |        |      |      |       |      |
+-----------------------+-----+--------+------+------+-------+------+
| g\. Other: (please    |     |        | ~1~  | ~2~  | ~3~   | ~4~  |
| specify)\_\_\_\_\     |     |        |      |      |       |      |
| _\_\_\_\_\_\_\_\_\_\_ |     |        |      |      |       |      |
+-----------------------+-----+--------+------+------+-------+------+

3\. At what points of contact are interpreters available for
in-patients?

####  Is patient use of interpreter services documented?

  ------------------------ ------------------ ------------------- ------------------ --------------------- ------------------
                           [No]{.underline}   [Yes]{.underline}   [No]{.underline}   [Yes, in Paper        [Yes, in
                                                                                     Record]{.underline}   Electronic
                                                                                                           MIS]{.underline}

  a\. At admission         ~0~                ~1~ IF YES          ~1~                ~2~                   ~3~

  b\. On patient units     ~0~                ~1~ IF YES          ~1~                ~2~                   ~3~

  c\. At discharge         ~0~                ~1~ IF YES          ~1~                ~2~                   ~3~
  ------------------------ ------------------ ------------------- ------------------ --------------------- ------------------

###  

### **Section B**

### **Advertising Interpreter Services**

## 

4\. Does this hospital include information on the availability of
interpreter services in brochures, outreach materials, marketing
information or any other material distributed to the public?

> ~0~ No IF NO, Go to Question 6
>
> ~1~ Yes

5\. In what languages is the information on interpreter services
available to the public?

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Spanish                                            ~0~                ~1~

  b\. Chinese                                            ~0~                ~1~

  c\. Vietnamese                                         ~0~                ~1~

  d\. Korean                                             ~0~                ~1~

  e\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  f\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  g\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      
  ------------------------------------------------------ ------------------ -------------------

### 

6\. Does this hospital post signs providing directions in languages
other than English?

> ~0~ No IF NO, Go to Question 8
>
> ~1~ Yes

7\. In what languages are the interpreter availability signs posted?

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Spanish                                            ~0~                ~1~

  b\. Chinese                                            ~0~                ~1~

  c\. Vietnamese                                         ~0~                ~1~

  d\. Korean                                             ~0~                ~1~

  e\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  f\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  g\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      
  ------------------------------------------------------ ------------------ -------------------

### **Section C**

### **Hospital Policies and Interpreter Certification**

8\. Does this hospital have a written policy and procedures about the:

***(Check One Box in Each Row)***

  ------------------------------------------------ ------------------ -------------------
                                                   [No]{.underline}   [Yes]{.underline}

  a\. Use of face-to-face interpreter services?    ~0~                ~1~

  b\. Use of telephone interpreter services?       ~0~                ~1~

  c\. Use of bilingual staff as interpreters?      ~0~                ~1~

  d\. Use of family or friends as interpreters?    ~0~                ~1~
  ------------------------------------------------ ------------------ -------------------

9.  Does the hospital require an assessment of:

> *[Who conducts the interpreter assessment?]{.underline}*

***(Mark All That Apply)***

  ------------------------------ ------------------ ------------------- -- -------------------- --------------------------
                                 [No]{.underline}   [Yes]{.underline}      [In-house            Vendor or
                                                                           Staff]{.underline}   [Contractor]{.underline}

  a\. Interpreter fluency in     ~0~                ~1~ IF YES             ~1~                  ~2~
  translating medical\                                                                          
  terms and procedures?                                                                         

  b\. Interpreter accuracy and   ~0~                ~1~ IF YES             ~1~                  ~2~
  completeness?                                                                                 
  ------------------------------ ------------------ ------------------- -- -------------------- --------------------------

10. Does the state have a certification requirement for interpreters?

> ~0~ No IF NO, Go to Question 12
>
> ~1~ Yes

11\. Which of the following languages are included in the state's
certification requirement?

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Spanish                                            ~0~                ~1~

  b\. Chinese                                            ~0~                ~1~

  c\. Vietnamese                                         ~0~                ~1~

  d\. Korean                                             ~0~                ~1~

  e\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  f\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  g\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      
  ------------------------------------------------------ ------------------ -------------------

12\. Does this hospital require that interpreters complete an
interpreter training program or to be certified?

> ~0~ NoIF NO, Go to Question 17
>
> ~1~ Yes

13\. How is the interpreter training or certification requirement
satisfied?

~1~ External training program or certification only

~2~ In house training program only

~3~ Both external training program or certification and in house
training program

14\. Which types of interpreters are included in the training or
certification requirement?

***(Check All That Apply)***

> ~1~ Professional interpreters
>
> ~2~ Volunteer interpreters
>
> ~3~ Bilingual staff

15\. Which of the following languages are included in the training or
certification requirement?

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Spanish                                            ~0~                ~1~

  b\. Chinese                                            ~0~                ~1~

  c\. Vietnamese                                         ~0~                ~1~

  d\. Korean                                             ~0~                ~1~

  e\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  f\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      

  g\. Other (please specify)                             ~0~                ~1~
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      
  ------------------------------------------------------ ------------------ -------------------

16\. Does the training or certification requirement include adherence to
a code of professional ethics?

> ~0~ No
>
> ~1~ Yes

### 

### **Section D**

### **Translation**

17. Does this hospital routinely translate any of its written materials
    to languages other than English?

~0~ No Go to Question 26

~1~ Yes Continue

18\. What types of written materials does this hospital routinely
provide to in-patients in languages other than English?

  -------------- ------------------ ------------------- --------------------------- ----------------------- -------------------------- ---------------------- --------------------- ---------------------
                                                        *[In what languages are                                                                                                     
                                                        written materials                                                                                                           
                                                        translated?]{.underline}*                                                                                                   

                 [No]{.underline}   [Yes]{.underline}   [Spanish]{.underline}       [Chinese]{.underline}   [Vietnamese]{.underline}   [Korean]{.underline}   [Other]{.underline}   [Othe]{.underline}r

  a\. Informed   ~0~                ~1~ IF YES          ~1~                         ~2~                     ~3~                        ~4~                    ~5~ \_\_\_\_\_\_      ~6~ \_\_\_\_\_\_
  consent                                                                                                                                                                           
  statements                                                                                                                                                                        

  b\. Medication ~0~                ~1~ IF YES          ~1~                         ~2~                     ~3~                        ~4~                    ~5~ \_\_\_\_\_\_      ~6~ \_\_\_\_\_\_
  instructions                                                                                                                                                                      

  c\. Discharge  ~0~                ~1~ IF YES          ~1~                         ~2~                     ~3~                        ~4~                    ~5~ \_\_\_\_\_\_      ~6~ \_\_\_\_\_\_
  planning                                                                                                                                                                          
  instructions                                                                                                                                                                      

  d\. Patient    ~0~                ~1~ IF YES          ~1~                         ~2~                     ~3~                        ~4~                    ~5~ \_\_\_\_\_\_      ~6~ \_\_\_\_\_\_
  advance                                                                                                                                                                           
  directives                                                                                                                                                                        

  e\. Health     ~0~                ~1~ IF YES          ~1~                         ~2~                     ~3~                        ~4~                    ~5~ \_\_\_\_\_\_      ~6~ \_\_\_\_\_\_
  education                                                                                                                                                                         
  material                                                                                                                                                                          
  -------------- ------------------ ------------------- --------------------------- ----------------------- -------------------------- ---------------------- --------------------- ---------------------

19\. What information does this hospital use in determining which
languages in-patient written material will be translated into?

> ***(Check All That Apply)***
>
> ~1~ Languages of service area population
>
> ~2~ Languages of in-patient population
>
> ~3~ Languages requested for interpreter services
>
> ~4~ Languages of service area population
>
> ~5~ Languages of in-patient population
>
> ~6~ Languages requested for interpreter services

20\. Does this hospital measure the reading level of the written
translations?

~0~ No Go to Question 22

~1~ Yes Continue

21\. What is the target reading level for written translations?

Enter grade level: \_\_\_\_\_\_\_\_\_\_\_\_ OR \_\_\_\_ We do not have a
target level

22\. Which of the following is used to produce this hospital's written
translations?\
***(Check All That Apply)***

  ------------------------------------------------ ------------------ -------------------
                                                   [No]{.underline}   [Yes]{.underline}

  a\. Use of computerized translation software?    ~0~                ~1~

  b\. Translation by an interpreter?               ~0~                ~1~

  c\. Translated materials are translated back     ~0~                ~1~
  into English for evaluation?                                        

  d\. Review of translations by an additional      ~0~                ~1~
  translator?                                                         

  e\. Evaluation of cultural appropriateness for   ~0~                ~1~
  targeted group?                                                     
  ------------------------------------------------ ------------------ -------------------

23\. Which types of translators are used in this hospital's translation
of written material?

***(Check All That Apply)***

> ~1~ Bilingual staff
>
> ~2~ Professional in-house translator(s)
>
> ~3~ Working group
>
> ~4~ Designated department
>
> ~5~ Outside vendors or contractors

24\. Are all translators required to demonstrate:

  ------------------------------------------------ ------------------ -------------------
                                                   [No]{.underline}   [Yes]{.underline}

  a\. Previous experience in translation?          ~0~                ~1~

  b\. Formal education or training in translation? ~0~                ~1~

  c\. Command of both English and the target       ~0~                ~1~
  language for translation?                                           

  d\. Familiarity with medical terminology?        ~0~                ~1~

  e\. Evaluation of cultural appropriateness for   ~0~                ~1~
  targeted group?                                                     
  ------------------------------------------------ ------------------ -------------------

25\. Are translated materials routinely reviewed in focus groups or by
representatives of community-based ethnic organizations?

> ~1~ No
>
> ~2~ Yes, focus groups
>
> ~3~ Yes, representatives of community organizations
>
> ~4~ Yes, both focus groups and representatives of community
> organizations

### 

### **Section E Climate**

26\. How true or false are the following statements about this hospital?

***(Check One Box on Each Line)***

+---------------------------------------+------+------+------+------+
|                                       | De   | Some | Some | De   |
|                                       | fini | what | what | fini |
|                                       | tely |      |      | tely |
|                                       |      | [Fa  | [T   |      |
|                                       | [Fa  | lse] | rue] | [T   |
|                                       | lse] | {.un | {.un | rue] |
|                                       | {.un | derl | derl | {.un |
|                                       | derl | ine} | ine} | derl |
|                                       | ine} |      |      | ine} |
+---------------------------------------+------+------+------+------+
| a\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| speak with enthusiasm\                |      |      |      |      |
| and commitment to the organization's  |      |      |      |      |
| agenda for a culturally\              |      |      |      |      |
| diverse work force                    |      |      |      |      |
+---------------------------------------+------+------+------+------+
| b\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| promote a culturally diverse work     |      |      |      |      |
| force as a competitive advantage      |      |      |      |      |
+---------------------------------------+------+------+------+------+
| c\. The CEO and top management team   | ~1~  | ~2~  | ~3~  | ~4~  |
| promote culturally competent care as  |      |      |      |      |
| a competitive advantage               |      |      |      |      |
+---------------------------------------+------+------+------+------+
| d\. This hospital not only tolerates  | ~1~  | ~2~  | ~3~  | ~4~  |
| but also values differences people    |      |      |      |      |
| bring to the workplace                |      |      |      |      |
+---------------------------------------+------+------+------+------+

### **Section F Personal Information**

The next few questions will help us to better design this survey and to
ensure it goes to the correct hospital representative.

27\. What is your job title at the hospital?

28\. What are your main duties and responsibilities?

29\. Do you have access to the Internet while at work?

> ~0~ No
>
> ~1~ Yes

30\. How many years have you been employed at the hospital?

\_\_\_\_\_\_\_ Number of Years

31\. In the future would it be easier to complete a survey like this...

> ~1~ Over the phone
>
> ~2~ Through the internet, or
>
> ~3~ On paper (like this one)?

32\. Did you find any questions or sections hard to complete?

> ~0~ No
>
> ~1~ Yes IF YES, (Please describe)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

33\. Did you require any assistance from another department in answering
any of these questions?

> ~0~ No
>
> ~1~ Yes IF YES, Which questions or sections? (Please describe)

34\. What department(s) did you get assistance from?

35\. May we contact you at a later time to ask you some question about
this survey?

> ~0~ No
>
> ~1~ Yes
>
> Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Phone
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Thanks for taking the time to complete this survey. Please use the
postage-paid envelope to return this survey to:

RAND

Attn: Kelly Sand

1700 Main Street

PO Box 2138

Santa Monica, CA 90407-2138

**Appendix D.2**

**Cultural Competency Assessment Tool for Hospitals (CCATH) Draft Used
in Focus Group Study**

**Cultural Competency Assessment Tool for Hospitals**

> ***Statement of Confidentiality***
>
> Any information that identifies you or your hospital will be kept
> confidential and used only for the purposes of this study. RAND will
> not release any information that identifies you without your prior
> consent, except as required by law.
>
> If you have questions about this study or your participation, please
> call the RAND Survey Coordinator, Kelly Sand, at 1-310-393-0411 ext.
> 7479.

  -----------------------------------------------------------------------
  **Survey Instructions**

  -----------------------------------------------------------------------

**Your hospital has been chosen to participate in the Cultural
Competency Assessment Tool for Hospitals (CCATH). The Office of Minority
Health, a federal agency within the U.S. Department of Health and Human
Services, sponsors this research.**

**As you fill out the booklet, please keep in mind that the information
you provide will be kept confidential. Below are some useful
instructions.**

g.  Please answer the questions in this survey booklet about the
    hospital where you received this survey.

h.  This survey covers several topics related to your hospital. Some
    sections may require assistance from other departments.

i.  Please answer each question, unless you are instructed to skip to a
    specific question. When you should skip over a question, you'll see
    an instruction that looks like this:

> **Is today Tuesday?**
>
> ~1~ Yes
>
> ~2~ No *IF NO, Go to Question 1*

j.  If you have any questions or need more information please call the
    RAND Survey Coordinator, Kelly Sand, at 1-310-393-0411, extension
    7479.

k.  When you have completed this survey booklet, please use the
    postage-paid envelope to return it to:

RAND

Attn: Kelly Sand

1700 Main Street

PO Box 2138

Santa Monica, CA 90407-2138

**Table of Contents**

### 

Section A: Culturally Competent Care 2

Section B: Human Resource Management 5

Section C: Translation and Interpreters 7

Section D: Leadership, Strategy, & Climate 10

Section E: Workforce Racial/Ethnic Composition 13

**Culturally Competent Care**

This first section consists of questions about linguistic and cultural
needs of patients receiving care at your hospital. Potential respondents
for this section consist of Directors of Patient Relations and
Vice-Presidents of Nursing.

***1. Does the staff at the Hospital: (Check One Box in Each Row)***

  --------------------------------------------- ------------------ -------------------------- --------------------------
                                                [No]{.underline}   [Yes, Some                 [Yes, Most
                                                                   Departments]{.underline}   Departments]{.underline}

  a\. Identify cultural and linguistic needs of ~1~               ~2~                       ~3~ 
  patients in the admission screening?                                                        

  b\. Identify cultural and linguistic needs    ~1~               ~2~                       ~3~ 
  during the discharge planning?                                                              

  c\. Accommodate the ethnic/cultural dietary   ~1~               ~2~                       ~3~ 
  preferences of patients?                                                                    

  d\. Incorporate information or knowledge      ~1~               ~2~                       ~3~ 
  about cultural beliefs into patient                                                         
  educational materials?                                                                      

  e\. Use clinical guidelines that incorporate  ~1~               ~2~                       ~3~ 
  information about cultural beliefs?                                                         

  f\. Use diagnostic tools that address         ~1~               ~2~                       ~3~ 
  differences of culture or language?                                                         
  --------------------------------------------- ------------------ -------------------------- --------------------------

2\. Does this hospital collect any ethnicity or racial data on
individuals receiving in-patient services?

> ~1~  No IF NO, Go to Question 4
>
> ~2~  Yes

3\. What percentage of this hospital\'s in-patient population is in the
following racial or ethnic categories? 

> (Check One Box in Each Line)

  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                   [Non]{.underline}e   [1% -             [6% -              [16% -             [26% -             More Than
                                                        5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. Hispanic or Latino           ~1~                 ~2~              ~3~               ~4~               ~5~               ~6~ 

  Non-Hispanic:                    ~1~                 ~2~              ~3~               ~4~               ~5~               ~6~ 

  b\. Asian or Pacific Islander    ~1~                 ~2~              ~3~               ~4~               ~5~               ~6~ 

  c\. American Indian or Alaska    ~1~                 ~2~              ~3~               ~4~               ~5~               ~6~ 
  Native                                                                                                                           

  d\. Black or African American    ~1~                 ~2~              ~3~               ~4~               ~5~               ~6~ 

  f\. White                        ~1~                 ~2~              ~3~               ~4~               ~5~               ~6~ 

  g\. Other (please specify)       ~1~                 ~2~              ~3~               ~4~               ~5~               ~6~ 
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                                                   
  -------------------------------- -------------------- ----------------- ------------------ ------------------ ------------------ -------------------

4\. Does this hospital collect data on the preferred language for
individuals receiving in-patient services?

> ~1~  No If No, Go to Question 6 (Human Resource Section)
>
> ~2~  Yes

5\. What percentage of this hospital\'s in-patient population is in the
following language categories?

***(Check One Box in Each Line)***

  ---------------------------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                           [1% -             [6% -              [16% -             [26% -             More Than
                                           5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. English                              ~1~              ~2~               ~3~               ~4~               ~5~ 

  b\. Spanish                              ~1~              ~2~               ~3~               ~4~               ~5~ 

  c\. Chinese                              ~1~              ~2~               ~3~               ~4~               ~5~ 

  d\. Vietnamese                           ~1~              ~2~               ~3~               ~4~               ~5~ 

  e\. Korean                               ~1~              ~2~               ~3~               ~4~               ~5~ 

  f\. Other (please specify)               ~1~              ~2~               ~3~               ~4~               ~5~ 
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              

  g\. Other (please specify)               ~1~              ~2~               ~3~               ~4~               ~5~ 
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              

  h\. Other (please specify)               ~1~              ~2~               ~3~               ~4~               ~5~ 
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              
  ---------------------------------------- ----------------- ------------------ ------------------ ------------------ -------------------

**Human Resource Management**

This next section consists of questions about staff benefits, available
training, and staff satisfaction. A human resources representative may
be the best person to fill out this section.

6\. Which of the following benefits are available to staff? *[Which
types of staff are eligible for these benefits?]{.underline}*

+-----------------------+---+---------+------+---------+-----------+
|                       | [ | [Ye     | Top  | Dep     | Nursing,  |
|                       | N | s]{.und |      | artment | Allied    |
|                       | o | erline} | [Man | Heads/  | Health    |
|                       | ] |         | agem |         | [or       |
|                       | { |         | ent] | # [Sup  | Support   |
|                       | . |         | {.un | ervisor | Staff]{.u |
|                       | u |         | derl | s]{.und | nderline} |
|                       | n |         | ine} | erline} |           |
|                       | d |         |      |         |           |
|                       | e |         |      |         |           |
|                       | r |         |      |         |           |
|                       | l |         |      |         |           |
|                       | i |         |      |         |           |
|                       | n |         |      |         |           |
|                       | e |         |      |         |           |
|                       | } |         |      |         |           |
+-----------------------+---+---------+------+---------+-----------+
| a\. Formal mentoring  | ~ | ~1~    | ~1~  | ~2~    | ~3~      |
| program               | 0 | IF YES  |     |         |           |
|                       | ~ |         |      |         |           |
|                       |  |         |      |         |           |
+-----------------------+---+---------+------+---------+-----------+
| b\. Management        | ~ | ~1~    | ~1~  | ~2~    | ~3~      |
| training              | 0 | IF YES  |     |         |           |
|                       | ~ |         |      |         |           |
|                       |  |         |      |         |           |
+-----------------------+---+---------+------+---------+-----------+
| c\. Tuition           | ~ | ~1~    | ~1~  | ~2~    | ~3~      |
| assistance or tuition | 0 | IF YES  |     |         |           |
| reimbursement for     | ~ |         |      |         |           |
| ongoing education     |  |         |      |         |           |
+-----------------------+---+---------+------+---------+-----------+
| d\. Personal          | ~ | ~1~    | ~1~  | ~2~    | ~3~      |
| counseling or         | 0 | IF YES  |     |         |           |
| employee\             | ~ |         |      |         |           |
| assistance programs   |  |         |      |         |           |
+-----------------------+---+---------+------+---------+-----------+
| e\. Flexible          | ~ | ~1~    | ~1~  | ~2~    | ~3~      |
| (cafeteria style)     | 0 | IF YES  |     |         |           |
|                       | ~ |         |      |         |           |
| benefits              |  |         |      |         |           |
+-----------------------+---+---------+------+---------+-----------+
| f\. Affinity          | ~ | ~1~    | ~1~  | ~2~    | ~3~      |
| (networking) groups   | 0 | IF YES  |     |         |           |
| for racial/ethnic     | ~ |         |      |         |           |
| minority staff        |  |         |      |         |           |
+-----------------------+---+---------+------+---------+-----------+
| g\. Work/life balance | ~ | ~1~    | ~1~  | ~2~    | ~3~      |
| programs such as      | 0 | IF YES  |     |         |           |
| flextime, job         | ~ |         |      |         |           |
| sharing, or           |  |         |      |         |           |
| telecommuting         |   |         |      |         |           |
+-----------------------+---+---------+------+---------+-----------+
| h\. Compensatory pay  | ~ | ~1~    | ~1~  | ~2~    | ~3~      |
| for bilingual staff   | 0 | IF YES  |     |         |           |
|                       | ~ |         |      |         |           |
|                       |  |         |      |         |           |
+-----------------------+---+---------+------+---------+-----------+

7\. Does this hospital track the race or ethnicity of its work force?

> ~0~  No
>
> ~1~  Yes

8\. Does this hospital conduct employee satisfaction surveys?

> ~0~  No IF NO, Go to Question 10
>
> ~1~  Yes

9\. Does the employee satisfaction survey address issues of diversity
climate?

> ~0~  No
>
> ~1~  Yes

10\. Does this hospital have a systematic training program on cultural
and linguistic diversity? Note: A systematic training program consists
of a formal, ongoing training program, which may consist of either a
stand-alone training program or several training components integrated
into other types of training.

> ~0~  No IF NO, Go to Question 13 (Translation and Interpreters
> Section)
>
> ~1~  Yes

11\. Is the training program voluntary or mandatory?

> ~0~  Voluntary Approximately what percentage of the hospital staff
> attend the voluntary training? \_\_\_\_\_\_\_\_%
>
> ~1~  MandatoryApproximately what percentage of the hospital staff
> attend the mandatory training? \_\_\_\_\_\_\_\_%

12\. Is it a stand alone training program, or is cultural and linguistic
diversity training integrated into other types of training?

> ~1~  Stand alone only
>
> ~2~  Integrated with other training only
>
> ~3~  Both stand alone and integrated with other training

####### Translation and Interpreters

The following section pertains to interpreting and translating services.
Examples of people who may have the necessary information to fill out
this section are Coordinators of Interpreter Services, Directors of
Patient Relations and Managers of Language Resources. **Please note that
an *interpreter* translates from one language to another
[orally]{.underline}. A *translator* translates [written]{.underline}
materials from the source language into another language.**

13\. In what languages are interpreter services available for
in-patients? *If Yes: [Which services are available?]{.underline}*

+------------------------+-----+-----+------+-------+-------+-------+
|                        | [   | [Y  | B    | Fa    | Fa    | Tele  |
|                        | No] | es] | ilin | ce-to | ce-to | phone |
|                        | {.u | {.u | gual | -Face | -Face | [Inte |
|                        | nde | nde | [St  | [     |       | rpret |
|                        | rli | rli | aff] | Profe | [Vo   | er]{. |
|                        | ne} | ne} | {.un | ssion | lunte | under |
|                        |     |     | derl | al]{. | er]{. | line} |
|                        |     |     | ine} | under | under |       |
|                        |     |     |      | line} | line} |       |
+------------------------+-----+-----+------+-------+-------+-------+
| a\. Spanish            | ~0~ | ~1~ | ~1~  | ~2~  | ~3~  | ~4~  |
|                        |    |    |     |       |       |       |
+------------------------+-----+-----+------+-------+-------+-------+
| b\. Chinese            | ~0~ | ~1~ | ~1~  | ~2~  | ~3~  | ~4~  |
|                        |    |    |     |       |       |       |
+------------------------+-----+-----+------+-------+-------+-------+
| c\. Vietnamese         | ~0~ | ~1~ | ~1~  | ~2~  | ~3~  | ~4~  |
|                        |    |    |     |       |       |       |
+------------------------+-----+-----+------+-------+-------+-------+
| d\. Korean             | ~0~ | ~1~ | ~1~  | ~2~  | ~3~  | ~4~  |
|                        |    |    |     |       |       |       |
+------------------------+-----+-----+------+-------+-------+-------+
| e\. Other: (please     |     |     | ~1~  | ~2~  | ~3~  | ~4~  |
| specify)\_\_\_\_       |     |     |     |       |       |       |
| \_\_\_\_\_\_\_\_\_\_\_ |     |     |      |       |       |       |
+------------------------+-----+-----+------+-------+-------+-------+
| f\. Other: (please     |     |     | ~1~  | ~2~  | ~3~  | ~4~  |
| specify)\_\_\_\_       |     |     |     |       |       |       |
| \_\_\_\_\_\_\_\_\_\_\_ |     |     |      |       |       |       |
+------------------------+-----+-----+------+-------+-------+-------+
| g\. Other: (please     |     |     | ~1~  | ~2~  | ~3~  | ~4~  |
| specify)\_\_\_\_       |     |     |     |       |       |       |
| \_\_\_\_\_\_\_\_\_\_\_ |     |     |      |       |       |       |
+------------------------+-----+-----+------+-------+-------+-------+

14\. Does this hospital include information on the availability of
interpreter services in brochures, written outreach materials, marketing
information or any other written material distributed to the public?

> ~0~  No
>
> ~1~  Yes

15\. Does this hospital have a written policy and procedures about the:

  ------------------------------------------------ ------------------ -------------------
                                                   [No]{.underline}   [Yes]{.underline}

  a\. Use of bilingual staff as interpreters?      ~0~               ~1~ 

  b\. Use of face-to-face interpreter services?    ~0~               ~1~ 

  c\. Use of telephone interpreter services?       ~0~               ~1~ 

  d\. Use of family or friends as interpreters?    ~0~               ~1~ 
  ------------------------------------------------ ------------------ -------------------

16\. Does the hospital require an assessment of: *[If Yes: Who conducts
the interpreter assessment?]{.underline}*

***(Mark All That Apply)***

  ----------------------------- ------------------ ------------------- -- -------------------- --------------------------
                                [No]{.underline}   [Yes]{.underline}      [In-house            Vendor or
                                                                          Staff]{.underline}   [Contractor]{.underline}

  a\. Interpreter fluency in    ~0~               ~1~                   ~1~                 ~2~ 
  translating medical\                                                                         
  terms and procedures?                                                                        

  B Interpreter accuracy and    ~0~               ~1~                   ~1~                 ~2~ 
  completeness?                                                                                
  ----------------------------- ------------------ ------------------- -- -------------------- --------------------------

17\. Does this hospital translate any of its written materials to
languages other than English?

~0~  No Go to Question 19

~1~  Yes Continue

18\. What types of written materials does this hospital routinely
provide to in-patients in languages other than English?

  -------------- ------------------ ------------------- --------------------------- ----------------------- -------------------------- ---------------------- --------------------- ---------------------
                                                        *[In what languages are                                                                                                     
                                                        written materials                                                                                                           
                                                        translated?]{.underline}*                                                                                                   

                 [No]{.underline}   [Yes]{.underline}   [Spanish]{.underline}       [Chinese]{.underline}   [Vietnamese]{.underline}   [Korean]{.underline}   [Other]{.underline}   [Othe]{.underline}r

  a\. Informed   ~0~               ~1~  IF YES       ~1~                        ~2~                    ~3~                       ~4~                   ~5~ \_\_\_\_\_\_     ~6~ \_\_\_\_\_\_
  consent                                                                                                                                                                           
  statements                                                                                                                                                                        

  b\. Medication ~0~               ~1~  IF YES       ~1~                        ~2~                    ~3~                       ~4~                   ~5~ \_\_\_\_\_\_     ~6~ \_\_\_\_\_\_
  instructions                                                                                                                                                                      

  c\. Discharge  ~0~               ~1~  IF YES       ~1~                        ~2~                    ~3~                       ~4~                   ~5~ \_\_\_\_\_\_     ~6~ \_\_\_\_\_\_
  planning                                                                                                                                                                          
  instructions                                                                                                                                                                      

  d\. Patient    ~0~               ~1~  IF YES       ~1~                        ~2~                    ~3~                       ~4~                   ~5~ \_\_\_\_\_\_     ~6~ \_\_\_\_\_\_
  advance                                                                                                                                                                           
  directives                                                                                                                                                                        

  e\. Health     ~0~               ~1~  IF YES       ~1~                        ~2~                    ~3~                       ~4~                   ~5~ \_\_\_\_\_\_     ~6~ \_\_\_\_\_\_
  education                                                                                                                                                                         
  material                                                                                                                                                                          
  -------------- ------------------ ------------------- --------------------------- ----------------------- -------------------------- ---------------------- --------------------- ---------------------

19\. Does this hospital post signs providing directions in languages
other than English?

> ~0~  No
>
> ~1~  Yes

####### Leadership, Strategy, & Climate 

The following section is about this hospital's strategic goals, and the
language and cultural needs of the service area. Potential respondents
for this section include the Vice-President for Planning/Business
Development and the Chief Operating Officer.

20\. Does this hospital's statement of strategic goals include:

*(Check One Box in Each Row)*

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Specific language about [recruitment]{.underline}  ~0~               ~1~ 
  of a culturally diverse work force?                                       

  b\. Specific language about [retention]{.underline} of ~0~               ~1~ 
  a culturally diverse work force?                                          

  c\. Specific language about the provision of           ~0~               ~1~ 
  culturally appropriate services?                                          
  ------------------------------------------------------ ------------------ -------------------

21\. Is there a person, office or committee who has dedicated
responsibility for promoting this hospital's cultural diversity goals?

> ~0~  No
>
> ~1~  Yes

22\. During the strategic planning process, did this hospital conduct an
organizational assessment to identify how well this organization met
current cultural diversity goals?

> ~0~  No
>
> ~1~  Yes

23\. Are the following assessments conducted as part of this hospital's
Quality Improvement activities?

+-------------------------+------+---------+---------+------+---------+
|                         |      |         |         |      |         |
+-------------------------+------+---------+---------+------+---------+
|                         | [No] | [Ye     | Less    | Once | More    |
|                         | {.un | s]{.und | Than    | Per  | Than    |
|                         | derl | erline} |         |      |         |
|                         | ine} |         | #       | [Y   | #       |
|                         |      |         |  [Once  | ear] |  [Once  |
|                         |      |         | Per Yea | {.un | Per Yea |
|                         |      |         | r]{.und | derl | r]{.und |
|                         |      |         | erline} | ine} | erline} |
+-------------------------+------+---------+---------+------+---------+
| a\. Accessibility of    | ~0~  | ~1~    | ~1~    | ~2~  | ~4~    |
| interpreter services    |     | IF YES  |         |     |         |
+-------------------------+------+---------+---------+------+---------+
| b\. Racial/ethnic       | ~0~  | ~1~    | ~1~    | ~2~  | ~4~    |
| differences in          |     | IF YES  |         |     |         |
| in-patient service use  |      |         |         |      |         |
+-------------------------+------+---------+---------+------+---------+
| c\. Racial/ethnic       | ~0~  | ~1~    | ~1~    | ~2~  | ~4~    |
| differences in patient  |     | IF YES  |         |     |         |
| assessments of care     |      |         |         |      |         |
| (satisfaction)          |      |         |         |      |         |
+-------------------------+------+---------+---------+------+---------+

24\. Does this hospital collect any of the following data on the
[population residing in the service area]{.underline}?

+-------------------------+------+---------+--------+------+----------+
|                         |      |         | *[How  |      |          |
|                         |      |         | often  |      |          |
|                         |      |         | is     |      |          |
|                         |      |         | this   |      |          |
|                         |      |         | data   |      |          |
|                         |      |         | collec |      |          |
|                         |      |         | ted?]{ |      |          |
|                         |      |         | .under |      |          |
|                         |      |         | line}* |      |          |
+-------------------------+------+---------+--------+------+----------+
|                         | [No] | [Ye     | Less   | Once | More     |
|                         | {.un | s]{.und | Than   | Per  | Than     |
|                         | derl | erline} |        |      |          |
|                         | ine} |         | # [On  | [Y   | # [On    |
|                         |      |         | ce Per | ear] | ce Per Y |
|                         |      |         |  Year] | {.un | ear]{.un |
|                         |      |         | {.unde | derl | derline} |
|                         |      |         | rline} | ine} |          |
+-------------------------+------+---------+--------+------+----------+
| a\. Race/ethnicity      | ~0~  | ~1~    | ~1~   | ~2~  | ~4~     |
|                         |     | IF YES  |        |     |          |
+-------------------------+------+---------+--------+------+----------+
| b\. Languages spoken    | ~0~  | ~1~    | ~1~   | ~2~  | ~4~     |
|                         |     | IF YES  |        |     |          |
+-------------------------+------+---------+--------+------+----------+
| c\. Income levels       | ~0~  | ~1~    | ~1~   | ~2~  | ~4~     |
|                         |     | IF YES  |        |     |          |
+-------------------------+------+---------+--------+------+----------+
| d\. Education levels    | ~0~  | ~1~    | ~1~   | ~2~  | ~4~     |
|                         |     | IF YES  |        |     |          |
+-------------------------+------+---------+--------+------+----------+
| e\. Health risks        | ~0~  | ~1~    | ~1~   | ~2~  | ~4~     |
| profile                 |     | IF YES  |        |     |          |
+-------------------------+------+---------+--------+------+----------+
| f\. Health conditions   | ~0~  | ~1~    | ~1~   | ~2~  | ~4~     |
| profile                 |     | IF YES  |        |     |          |
+-------------------------+------+---------+--------+------+----------+
| g\. Utilization of      | ~0~  | ~1~    | ~1~   | ~2~  | ~4~     |
| health screening        |     | IF YES  |        |     |          |
| services\               |      |         |        |      |          |
| (mammograms, prostate   |      |         |        |      |          |
| screening exams, PAP    |      |         |        |      |          |
| smears)                 |      |         |        |      |          |
+-------------------------+------+---------+--------+------+----------+

25\. Are community representatives involved in the

***(Check One Box in Each Row)***

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Planning and design of in-patient services for     ~0~               ~1~ 
  culturally diverse populations?                                           

  b\. Evaluation of existing services for culturally     ~0~               ~1~ 
  diverse populations?                                                      
  ------------------------------------------------------ ------------------ -------------------

26\. Do the staff involved in the formal complaint and grievance
process:

+-----------------------+-----+--------+-------+------+--------+----+
|                       |     |        | *[How |      |        |    |
|                       |     |        | often |      |        |    |
|                       |     |        | does  |      |        |    |
|                       |     |        | tra   |      |        |    |
|                       |     |        | ining |      |        |    |
|                       |     |        | occur |      |        |    |
|                       |     |        | ?]{.u |      |        |    |
|                       |     |        | nderl |      |        |    |
|                       |     |        | ine}* |      |        |    |
+-----------------------+-----+--------+-------+------+--------+----+
|                       | [   | [Yes]  | Less  | Once | More   |    |
|                       | No] | {.unde | Than  | Per  | Than   |    |
|                       | {.u | rline} |       |      |        |    |
|                       | nde |        | # [O  | [Y   | # [On  |    |
|                       | rli |        | nce P | ear] | ce Per |    |
|                       | ne} |        | er Ye | {.un |  Year] |    |
|                       |     |        | ar]{. | derl | {.unde |    |
|                       |     |        | under | ine} | rline} |    |
|                       |     |        | line} |      |        |    |
+-----------------------+-----+--------+-------+------+--------+----+
| a\. Receive formal    | ~0~ | ~1~   | ~1~  | ~2~  | ~4~   |    |
| training in conflict  |    | IF YES |       |     |        |    |
| resolution?           |     |        |       |      |        |    |
+-----------------------+-----+--------+-------+------+--------+----+
| b\. Receive formal    | ~0~ | ~1~   | ~1~  | ~2~  | ~4~   |    |
| training about        |    | IF YES |       |     |        |    |
| cultural or language  |     |        |       |      |        |    |
| differences?          |     |        |       |      |        |    |
+-----------------------+-----+--------+-------+------+--------+----+

27\. Does this hospital routinely report to the public information about
its performance in meeting the cultural and linguistics needs of the
service area?

> ~0~  No
>
> ~1~  Yes

##  

## Workforce Racial/Ethnic Composition

The follow section asks for information about the diversity of your
hospital's workforce. This form is similar to the Equal Employment
Opportunity Report (EEO-1) filled out by the human resources department
of your hospital. If you have a copy of your EEO-1 report, feel free to
send it instead of filling out the form. If you would like assistance
with the categories as they pertain to hospital employees, please see
the Equal Employment Opportunities Commission web site
<http://www.eeoc.gov/eeo1survey/>

28. *What percentage of this hospital's work force is in the following
    racial or ethnic categories?*

<table style="width:100%;">
<colgroup>
<col style="width: 17%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="5"><strong>Male</strong></td>
<td colspan="5"><strong>Female</strong></td>
</tr>
<tr class="even">
<td></td>
<td><p>White (non-Hispanic)</p>
<p>A.</p></td>
<td><p>Black (non-Hispanic)</p>
<p>B.</p></td>
<td><p>Hispanic</p>
<p>C.</p></td>
<td><p>Asian or</p>
<p>Pacific Islander</p>
<p>D.</p></td>
<td><p>American Indian or Alaskan Native</p>
<p>E.</p></td>
<td><p>White (non-Hispanic)</p>
<p>F.</p></td>
<td><p>Black (non-Hispanic)</p>
<p>G.</p></td>
<td><p>Hispanic</p>
<p>H.</p></td>
<td><p>Asian or Pacific Islander</p>
<p>I.</p></td>
<td><p>American Indian or Alaskan Native</p>
<p>J</p></td>
</tr>
<tr class="odd">
<td><strong>Officials &amp; Managers</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Professionals</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Technicians</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Sales Workers</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Office &amp; Clerical</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Craft Workers (Skilled)</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Operatives (Semi-Skilled)</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Laborers (Unskilled)</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Service Workers</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td><strong>TOTAL</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Appendix D.3**

**Cultural Competency Assessment Tool for Hospitals (CCATH) Draft\
Used For Cognitive Interviews**

**Cultural Competency Assessment Tool for Hospitals**

> ***Statement of Confidentiality***
>
> Any information that identifies you or your hospital will be kept
> confidential and used only for the purposes of this study. RAND will
> not release any information that identifies you without your prior
> consent, except as required by law.
>
> If you have questions about this study or your participation, please
> call the RAND Survey Coordinator, Kelly Sand, at 1-310-393-0411 ext.
> 7479.

**November 30, 2005**

  -----------------------------------------------------------------------
  **Survey Instructions**

  -----------------------------------------------------------------------

**Your hospital has been chosen to participate in the Cultural
Competency Assessment Tool for Hospitals (CCATH). The Office of Minority
Health, a federal agency within the U.S. Department of Health and Human
Services, sponsors this research.**

**As you fill out the booklet, please keep in mind that the information
you provide will be kept confidential. Below are some useful
instructions.**

a.  Please answer the questions in this survey booklet about the
    hospital where you received this survey.

b.  This survey covers several topics related to your hospital. Some
    sections may require assistance from other departments.

c.  Please answer each question, unless you are instructed to skip to a
    specific question. When you should skip over a question, you'll see
    an instruction that looks like this:

> **Is today Tuesday?**
>
> ~1~ Yes
>
> ~2~ No *IF NO, Go to Question 1*

d.  If you have any questions or need more information please call the
    RAND Survey Coordinator, Kelly Sand, at 1-310-393-0411, extension
    7479.

e.  When you have completed this survey booklet, please use the
    postage-paid envelope to return it to:

RAND

Attn: Kelly Sand

1700 Main Street

PO Box 2138

Santa Monica, CA 90407-2138

**Table of Contents**

### 

Section A: Culturally Competent Care 2

Section B: Human Resource Management 5

Section C: Translation and Interpreters 7

Section D: Leadership, Strategy, & Climate 10

Section E: Workforce Racial/Ethnic Composition 13

**Culturally Competent Care**

This first section consists of questions about language and cultural
needs of the in-patient populations receiving care at your hospital.
Potential respondents for this section consist of Directors of Patient
Relations and Vice-Presidents of Nursing.

***1. Does the staff at the Hospital: (Check One Box in Each Row)***

  ----------------------------------------------- ------------------ -------------------------- --------------------------
                                                  [No]{.underline}   [Yes, less than half of    [Yes, half or more of the
                                                                     the                        departments]{.underline}
                                                                     departments]{.underline}   

  a\. Identify cultural and language needs of     ~1~               ~2~                       ~3~ 
  in-patients in the admission screening?                                                       

  b\. Identify cultural and language needs during ~1~               ~2~                       ~3~ 
  the discharge planning?                                                                       

  c\. Accommodate the ethnic/cultural dietary     ~1~               ~2~                       ~3~ 
  preferences of in-patients?                                                                   

  d\. Incorporate information or knowledge about  ~1~               ~2~                       ~3~ 
  cultural beliefs into patient educational                                                     
  materials?                                                                                    

  e\. Are cultural differences considered in the  ~1~               ~2~                       ~3~ 
  use of clinical guidelines?                                                                   

  f\. Use assessment tools that address           ~1~               ~2~                       ~3~ 
  differences of culture or language?                                                           
  ----------------------------------------------- ------------------ -------------------------- --------------------------

2\. Does this hospital collect any ethnicity or racial data on
individuals receiving in-patient services?

> ~1~  No IF NO, Go to Question 4
>
> ~2~  Yes

3\. What percentage of this hospital\'s in-patient population is in the
following racial or ethnic categories? 

> (Check One Box in Each Line)

+--------------------------+-----+------+------+------+------+------+
|                          | [No | [    | [    | [1   | > [2 | More |
|                          | n]{ | 1% - | 6% - | 6% - | 6% - | Than |
|                          | .un | 5%]  | 15%] | 25%] | >    | [    |
|                          | der | {.un | {.un | {.un | 50%] | 50%] |
|                          | lin | derl | derl | derl | {.un | {.un |
|                          | e}e | ine} | ine} | ine} | derl | derl |
|                          |     |      |      |      | ine} | ine} |
+--------------------------+-----+------+------+------+------+------+
| a\. Hispanic or Latino   | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
|                          |    |     |     |     |     |     |
+--------------------------+-----+------+------+------+------+------+
| Non-Hispanic:            | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
|                          |    |     |     |     |     |     |
+--------------------------+-----+------+------+------+------+------+
| b\. Asian or Pacific     | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
| Islander                 |    |     |     |     |     |     |
+--------------------------+-----+------+------+------+------+------+
| c\. American Indian or   | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
| Alaska Native            |    |     |     |     |     |     |
+--------------------------+-----+------+------+------+------+------+
| d\. Black or African     | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
| American                 |    |     |     |     |     |     |
+--------------------------+-----+------+------+------+------+------+
| f\. White                | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
|                          |    |     |     |     |     |     |
+--------------------------+-----+------+------+------+------+------+
| g\. Other (please        | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
| specify)                 |    |     |     |     |     |     |
| \_\_\_                   |     |      |      |      |      |      |
| \_\_\_\_\_\_\_\_\_\_\_\_ |     |      |      |      |      |      |
+--------------------------+-----+------+------+------+------+------+

4\. Does this hospital collect data on the preferred language for
individuals receiving in-patient services?

> ~1~  No If No, Go to Question 6 (Human Resource Section)
>
> ~2~  Yes

5\. What percentage of this hospital\'s in-patient population is in the
following language categories?

***(Check One Box in Each Line)***

  ---------------------------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                           [1% -             [6% -              [16% -             [26% -             More Than
                                           5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. English                              ~1~              ~2~               ~3~               ~4~               ~5~ 

  b\. Spanish                              ~1~              ~2~               ~3~               ~4~               ~5~ 

  c\. Chinese                              ~1~              ~2~               ~3~               ~4~               ~5~ 

  d\. French                               ~1~              ~2~               ~3~               ~4~               ~5~ 

  e\. German                               ~1~              ~2~               ~3~               ~4~               ~5~ 

  f\. Tagalog                              ~1~              ~2~               ~3~               ~4~               ~5~ 

  G. Other (please specify)                ~1~              ~2~               ~3~               ~4~               ~5~ 
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              

  h\. Other (please specify)               ~1~              ~2~               ~3~               ~4~               ~5~ 
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              

  I. Other (please specify)                ~1~              ~2~               ~3~               ~4~               ~5~ 
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              
  ---------------------------------------- ----------------- ------------------ ------------------ ------------------ -------------------

> **Human Resource Management**

This next section consists of questions about staff benefits, available
training, and staff satisfaction. A human resources representative may
be the best person to fill out this section.

6\. Which of the following benefits are available to staff? *[Which
types of staff are eligible for these benefits?]{.underline}*

+------------------------+----+----------+-------+----------+----------+
|                        | [N | [        | Top   | De       | N        |
|                        | o] | Yes]{.un |       | partment | ursing,\ |
|                        | {. | derline} | [Man  | Heads/   | Allied   |
|                        | un |          | ageme |          | Health\  |
|                        | de |          | nt]{. | # [      | [or      |
|                        | rl |          | under | Supervis | Support  |
|                        | in |          | line} | ors]{.un | St       |
|                        | e} |          |       | derline} | aff]{.un |
|                        |    |          |       |          | derline} |
+------------------------+----+----------+-------+----------+----------+
| a\. Formal mentoring   | ~  | ~1~  IF | ~1~  | ~2~     | ~3~     |
| program                | 0~ | YES      |       |          |          |
|                        |   |          |       |          |          |
+------------------------+----+----------+-------+----------+----------+
| b\. Management         | ~  | ~1~  IF | ~1~  | ~2~     | ~3~     |
| training               | 0~ | YES      |       |          |          |
|                        |   |          |       |          |          |
+------------------------+----+----------+-------+----------+----------+
| c\. Tuition assistance | ~  | ~1~  IF | ~1~  | ~2~     | ~3~     |
| or tuition             | 0~ | YES      |       |          |          |
| reimbursement for      |   |          |       |          |          |
| ongoing education      |    |          |       |          |          |
+------------------------+----+----------+-------+----------+----------+
| d\. Personal           | ~  | ~1~  IF | ~1~  | ~2~     | ~3~     |
| counseling or          | 0~ | YES      |       |          |          |
| employee\              |   |          |       |          |          |
| assistance programs    |    |          |       |          |          |
+------------------------+----+----------+-------+----------+----------+
| e\. Flexible benefits  | ~  | ~1~  IF | ~1~  | ~2~     | ~3~     |
|                        | 0~ | YES      |       |          |          |
|                        |   |          |       |          |          |
+------------------------+----+----------+-------+----------+----------+
| f\. Affinity           | ~  | ~1~  IF | ~1~  | ~2~     | ~3~     |
| (networking) groups    | 0~ | YES      |       |          |          |
| for racial/ethnic      |   |          |       |          |          |
| minority staff         |    |          |       |          |          |
+------------------------+----+----------+-------+----------+----------+
| g\. Work/life balance  | ~  | ~1~  IF | ~1~  | ~2~     | ~3~     |
| programs such as       | 0~ | YES      |       |          |          |
| flextime, job sharing  |   |          |       |          |          |
| or telecommuting       |    |          |       |          |          |
+------------------------+----+----------+-------+----------+----------+
| h\. Compensatory pay   | ~  | ~1~  IF | ~1~  | ~2~     | ~3~     |
| for bilingual staff    | 0~ | YES      |       |          |          |
|                        |   |          |       |          |          |
+------------------------+----+----------+-------+----------+----------+

7\. Does this hospital track the race or ethnicity of its work force?

> ~0~  No
>
> ~1~  Yes

8\. Does this hospital conduct employee satisfaction surveys?

> ~0~  No IF NO, Go to Question 10
>
> ~1~  Yes

9\. Does the employee satisfaction survey include measures of diversity
climate?

> ~0~  No
>
> ~1~  Yes

10\. Does this hospital have a systematic training program on cultural
and language diversity? Note: A systematic training program consists of
a formal, ongoing training program, which may consist of either a
stand-alone training program or several training components integrated
into other types of training.

> ~0~  No IF NO, Go to Question 13 (Translation and Interpreters
> Section)
>
> ~1~  Yes

11\. Is the training program voluntary or mandatory?

> ~0~  Voluntary Approximately what percentage of the hospital staff
> attend the voluntary training? \_\_\_\_\_\_\_\_%
>
> ~1~  MandatoryApproximately what percentage of the hospital staff
> attend the mandatory training? \_\_\_\_\_\_\_\_%

~2~  Both voluntary and mandatory programs

###### Approximately what percentage of the hospital staff attend the voluntary training? \_\_\_\_\_\_\_\_%

######## Approximately what percentage of the hospital staff attend the mandatory training? \_\_\_\_\_\_\_\_%

12\. Is it a stand alone training program, or is cultural and language
diversity training integrated into other types of training?

> ~1~  Stand alone only
>
> ~2~  Integrated with other training only
>
> ~3~  Both stand alone and integrated with other training

Translation and Interpreters

The following section pertains to interpreting and translating services.
Examples of people who may have the necessary information to fill out
this section are Coordinators of Interpreter Services, Directors of
Patient Relations and Managers of Language Resources. **Please note that
an *interpreter* translates from one language to another
[orally]{.underline}. A *translator* translates [written]{.underline}
materials from the source language into another language.**

13\. In what languages are interpreter services available for
in-patients? *If Yes: [Which services are available?]{.underline}*

+-------------------------+----+-----+-------+-------+------+-----+
|                         | [N | [Y  | Bili  | Fa    | Face | Tel |
|                         | o] | es] | ngual | ce-to | -to- | eph |
|                         | {. | {.u | S     | -Face | Face | one |
|                         | un | nde | taff\ | Pr    |      | In  |
|                         | de | rli | [as   | ofess | V    | ter |
|                         | rl | ne} | inter | ional | olun | pre |
|                         | in |     | prete | [     | teer | ter |
|                         | e} |     | rs]{. | Inter | [I   |     |
|                         |    |     | under | prete | nter | [   |
|                         |    |     | line} | rs]{. | pret | Ser |
|                         |    |     |       | under | ers] | vic |
|                         |    |     |       | line} | {.un | es] |
|                         |    |     |       |       | derl | {.u |
|                         |    |     |       |       | ine} | nde |
|                         |    |     |       |       |      | rli |
|                         |    |     |       |       |      | ne} |
+-------------------------+----+-----+-------+-------+------+-----+
| a\. Spanish             | ~  | ~1~ | ~1~  | ~2~  | ~3~  | ~4~ |
|                         | 0~ |    |       |       |     |    |
|                         |   |     |       |       |      |     |
+-------------------------+----+-----+-------+-------+------+-----+
| b\. Chinese             | ~  | ~1~ | ~1~  | ~2~  | ~3~  | ~4~ |
|                         | 0~ |    |       |       |     |    |
|                         |   |     |       |       |      |     |
+-------------------------+----+-----+-------+-------+------+-----+
| d\. French              | ~  | ~1~ | ~1~  | ~2~  | ~3~  | ~4~ |
|                         | 0~ |    |       |       |     |    |
|                         |   |     |       |       |      |     |
+-------------------------+----+-----+-------+-------+------+-----+
| e\. German              | ~  | ~1~ | ~1~  | ~2~  | ~3~  | ~4~ |
|                         | 0~ |    |       |       |     |    |
|                         |   |     |       |       |      |     |
+-------------------------+----+-----+-------+-------+------+-----+
| f\. Tagalong            | ~  | ~1~ | ~1~  | ~2~  | ~3~  | ~4~ |
|                         | 0~ |    |       |       |     |    |
|                         |   |     |       |       |      |     |
+-------------------------+----+-----+-------+-------+------+-----+
| g\. Other (please       |    |     | ~1~  | ~2~  | ~3~  | ~4~ |
| specify)                |    |     |       |       |     |    |
| \_\_\                   |    |     |       |       |      |     |
| _\_\_\_\_\_\_\_\_\_\_\_ |    |     |       |       |      |     |
+-------------------------+----+-----+-------+-------+------+-----+
| h\. Other (please       |    |     | ~1~  | ~2~  | ~3~  | ~4~ |
| specify)                |    |     |       |       |     |    |
| \_\_\                   |    |     |       |       |      |     |
| _\_\_\_\_\_\_\_\_\_\_\_ |    |     |       |       |      |     |
+-------------------------+----+-----+-------+-------+------+-----+
| i\. Other (please       |    |     | ~1~  | ~2~  | ~3~  | ~4~ |
| specify)                |    |     |       |       |     |    |
| \_\_\                   |    |     |       |       |      |     |
| _\_\_\_\_\_\_\_\_\_\_\_ |    |     |       |       |      |     |
+-------------------------+----+-----+-------+-------+------+-----+

14\. Does this hospital include information on the availability of
interpreter services in brochures, written outreach materials, marketing
information or any other written material distributed to the public?

> ~0~  No
>
> ~1~  Yes

15\. Does this hospital have a written policy and procedures about the:

  -------------------------------------------------- ------------------ -------------------
                                                     [No]{.underline}   [Yes]{.underline}

  a\. Use of bilingual staff as interpreters?        ~0~               ~1~ 

  b\. Use of face-to-face professional               ~0~               ~1~ 
  interpreters?.                                                        

  c\. Use of face-to-face volunteer interpreters?    ~0~               ~1~ 

  d\. Use of telephone interpreter services?         ~0~               ~1~ 

  e\. Use of family or friends as interpreters?      ~0~               ~1~ 
  -------------------------------------------------- ------------------ -------------------

16\. Does the hospital require an assessment of: *[If Yes: Who conducts
the interpreter assessment?]{.underline}*

***(Mark All That Apply)***

  ----------------------------- ------------------ ------------------- -- -------------------- --------------------------
                                [No]{.underline}   [Yes]{.underline}      [In-house            Vendor or
                                                                          Staff]{.underline}   [Contractor]{.underline}

  a\. Interpreter fluency in    ~0~               ~1~                   ~1~                 ~2~ 
  translating medical\                                                                         
  terms and procedures?                                                                        

  b\. Interpreter accuracy and  ~0~               ~1~                   ~1~                 ~2~ 
  completeness?                                                                                
  ----------------------------- ------------------ ------------------- -- -------------------- --------------------------

17\. Does this hospital translate any of its written materials for
in-patient populations to languages other than English?

~0~  No Go to Question 19

~1~  Yes Continue

18\. What types of written materials does this hospital routinely
provide to in-patients in languages other than English?

<table>
<colgroup>
<col style="width: 18%" />
<col style="width: 4%" />
<col style="width: 13%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 11%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td colspan="7"><em><u>In what languages are written materials
translated?</u></em></td>
</tr>
<tr class="even">
<td></td>
<td><u>No</u></td>
<td><u>Yes</u></td>
<td><u>Spanish</u></td>
<td><u>Chinese</u></td>
<td><u>French</u></td>
<td><u>German</u></td>
<td><u>Tagalog</u></td>
<td><p><u>Other</u></p>
<p>Please specify:</p>
<p><u>__________</u></p></td>
<td><p><u>Othe</u>r</p>
<p>Please specify:</p>
<p>_________</p></td>
</tr>
<tr class="odd">
<td>a. Informed consent statements</td>
<td><sub>0</sub> </td>
<td><sub>1</sub>  IF YES</td>
<td><sub>1</sub> </td>
<td><sub>2</sub> </td>
<td><sub>3</sub> </td>
<td><sub>4</sub> </td>
<td><sub>5</sub> </td>
<td><sub>5</sub> </td>
<td><sub>6</sub> </td>
</tr>
<tr class="even">
<td>b. Medication instructions</td>
<td><sub>0</sub> </td>
<td><sub>1</sub>  IF YES</td>
<td><sub>1</sub> </td>
<td><sub>2</sub> </td>
<td><sub>3</sub> </td>
<td><sub>4</sub> </td>
<td><sub>5</sub> </td>
<td><sub>5</sub> </td>
<td><sub>6</sub> </td>
</tr>
<tr class="odd">
<td>c. Discharge planning instructions</td>
<td><sub>0</sub> </td>
<td><sub>1</sub>  IF YES</td>
<td><sub>1</sub> </td>
<td><sub>2</sub> </td>
<td><sub>3</sub> </td>
<td><sub>4</sub> </td>
<td><sub>5</sub> </td>
<td><sub>5</sub> </td>
<td><sub>6</sub> </td>
</tr>
<tr class="even">
<td>d. Patient advance directives</td>
<td><sub>0</sub> </td>
<td><sub>1</sub>  IF YES</td>
<td><sub>1</sub> </td>
<td><sub>2</sub> </td>
<td><sub>3</sub> </td>
<td><sub>4</sub> </td>
<td><sub>5</sub> </td>
<td><sub>5</sub> </td>
<td><sub>6</sub> </td>
</tr>
<tr class="odd">
<td>e. Health education material</td>
<td><sub>0</sub> </td>
<td><sub>1</sub>  IF YES</td>
<td><sub>1</sub> </td>
<td><sub>2</sub> </td>
<td><sub>3</sub> </td>
<td><sub>4</sub> </td>
<td><sub>5</sub> </td>
<td><sub>5</sub> </td>
<td><sub>6</sub> </td>
</tr>
</tbody>
</table>

19\. Does this hospital post signs providing directions in languages
other than English?

> ~0~  No
>
> ~1~  Yes

####### Leadership, Strategy, & Climate 

The following section is about this hospital's strategic goals, and the
language and cultural needs of the service area. Potential respondents
for this section include the Vice-President for Planning/Business
Development and the Chief Operating Officer.

20\. Does this hospital's statement of strategic goals include:

***(Check One Box in Each Row)***

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Specific language about [recruitment]{.underline}  ~0~               ~1~ 
  of a culturally diverse work force?                                       

  b\. Specific language about [retention]{.underline} of ~0~               ~1~ 
  a culturally diverse work force?                                          

  c\. Specific language about the provision of           ~0~               ~1~ 
  culturally appropriate services?                                          
  ------------------------------------------------------ ------------------ -------------------

21\. Is there a person, office or committee who has dedicated
responsibility for promoting this hospital's cultural diversity goals?

> ~0~  No
>
> ~1~  Yes

22\. During the strategic planning process, did this hospital conduct an
organizational assessment to identify how well this organization met
current cultural diversity goals?

> ~0~  No
>
> ~1~  Yes

23\. Are the following assessments conducted as part of this hospital's
quality improvement activities?

+------------------------+----+---------+-------+-----+-------+----+
|                        |    |         | #     |     |       |    |
|                        |    |         | ####  |     |       |    |
|                        |    |         | How o |     |       |    |
|                        |    |         | ften  |     |       |    |
|                        |    |         | is it |     |       |    |
|                        |    |         |  asse |     |       |    |
|                        |    |         | ssed? |     |       |    |
+------------------------+----+---------+-------+-----+-------+----+
|                        | [N | [Ye     | Less  | O   | More  | #  |
|                        | o] | s]{.und | Than  | nce | Than  |  [ |
|                        | {. | erline} |       | Per |       | On |
|                        | un |         | # [O  |     | # [O  | go |
|                        | de |         | nce P | [Ye | nce P | in |
|                        | rl |         | er Ye | ar] | er Ye | g] |
|                        | in |         | ar]{. | {.u | ar]{. | {. |
|                        | e} |         | under | nde | under | un |
|                        |    |         | line} | rli | line} | de |
|                        |    |         |       | ne} |       | rl |
|                        |    |         |       |     |       | in |
|                        |    |         |       |     |       | e} |
+------------------------+----+---------+-------+-----+-------+----+
| a\. Accessibility of   | ~  | ~1~    | ~1~  | ~2~ | ~3~  | ~  |
| interpreter services   | 0~ | IF YES  |       |    |       | 4~ |
|                        |   |         |       |     |       |   |
+------------------------+----+---------+-------+-----+-------+----+
| b\. Racial/ethnic      | ~  | ~1~    | ~1~  | ~2~ | ~3~  | ~  |
| differences in         | 0~ | IF YES  |       |    |       | 4~ |
| in-patient service use |   |         |       |     |       |   |
+------------------------+----+---------+-------+-----+-------+----+
| c\. Racial/ethnic      | ~  | ~1~    | ~1~  | ~2~ | ~3~  | ~  |
| differences in         | 0~ | IF YES  |       |    |       | 4~ |
| in-patient assessments |   |         |       |     |       |   |
| of care (satisfaction) |    |         |       |     |       |    |
+------------------------+----+---------+-------+-----+-------+----+

24\. Does this hospital collect or receive any of the following data on
the [population residing in the service area]{.underline}?

+------------------------+----+---------+-------+------+-------+----+
|                        |    |         | *[How |      |       |    |
|                        |    |         | often |      |       |    |
|                        |    |         | is    |      |       |    |
|                        |    |         | this  |      |       |    |
|                        |    |         | data  |      |       |    |
|                        |    |         | coll  |      |       |    |
|                        |    |         | ected |      |       |    |
|                        |    |         | or    |      |       |    |
|                        |    |         | rec   |      |       |    |
|                        |    |         | eived |      |       |    |
|                        |    |         | ?]{.u |      |       |    |
|                        |    |         | nderl |      |       |    |
|                        |    |         | ine}* |      |       |    |
+------------------------+----+---------+-------+------+-------+----+
|                        | [N | [Ye     | Less  | Once | More  | #  |
|                        | o] | s]{.und | Than  | Per  | Than  |  [ |
|                        | {. | erline} |       |      |       | On |
|                        | un |         | # [O  | [Y   | # [O  | go |
|                        | de |         | nce P | ear] | nce P | in |
|                        | rl |         | er Ye | {.un | er Ye | g] |
|                        | in |         | ar]{. | derl | ar]{. | {. |
|                        | e} |         | under | ine} | under | un |
|                        |    |         | line} |      | line} | de |
|                        |    |         |       |      |       | rl |
|                        |    |         |       |      |       | in |
|                        |    |         |       |      |       | e} |
+------------------------+----+---------+-------+------+-------+----+
| a\. Race/ethnicity     | ~  | ~1~    | ~1~  | ~2~  | ~3~  | ~  |
|                        | 0~ | IF YES  |       |     |       | 4~ |
|                        |   |         |       |      |       |   |
+------------------------+----+---------+-------+------+-------+----+
| b\. Languages spoken   | ~  | ~1~    | ~1~  | ~2~  | ~3~  | ~  |
|                        | 0~ | IF YES  |       |     |       | 4~ |
|                        |   |         |       |      |       |   |
+------------------------+----+---------+-------+------+-------+----+
| c\. Income levels      | ~  | ~1~    | ~1~  | ~2~  | ~3~  | ~  |
|                        | 0~ | IF YES  |       |     |       | 4~ |
|                        |   |         |       |      |       |   |
+------------------------+----+---------+-------+------+-------+----+
| d\. Education levels   | ~  | ~1~    | ~1~  | ~2~  | ~3~  | ~  |
|                        | 0~ | IF YES  |       |     |       | 4~ |
|                        |   |         |       |      |       |   |
+------------------------+----+---------+-------+------+-------+----+
| e\. Health risks       | ~  | ~1~    | ~1~  | ~2~  | ~3~  | ~  |
| profile                | 0~ | IF YES  |       |     |       | 4~ |
|                        |   |         |       |      |       |   |
+------------------------+----+---------+-------+------+-------+----+
| f\. Community needs    | ~  | ~1~    | ~1~  | ~2~  | ~3~  | ~  |
| assessment             | 0~ | IF YES  |       |     |       | 4~ |
|                        |   |         |       |      |       |   |
+------------------------+----+---------+-------+------+-------+----+
| g\. Utilization of     | ~  | ~1~    | ~1~  | ~2~  | ~3~  | ~  |
| health screening       | 0~ | IF YES  |       |     |       | 4~ |
| services\              |   |         |       |      |       |   |
| (mammograms, prostate  |    |         |       |      |       |    |
| screening exams, PAP   |    |         |       |      |       |    |
| smears)                |    |         |       |      |       |    |
+------------------------+----+---------+-------+------+-------+----+

25\. Are community representatives involved in the

***(Check One Box in Each Row)***

  -------------------------------------------------------- ------------------ -------------------
                                                           [No]{.underline}   [Yes]{.underline}

  a\. Planning and design of in-patient services for       ~0~               ~1~ 
  culturally diverse populations?                                             

  b\. Evaluation of existing services for culturally       ~0~               ~1~ 
  diverse populations?                                                        
  -------------------------------------------------------- ------------------ -------------------

26\. Do the staff involved in the formal complaint and grievance
process:

+-------------------------+------+---------+--------+-------+----------+
|                         |      |         | *[How  |       |          |
|                         |      |         | often  |       |          |
|                         |      |         | does   |       |          |
|                         |      |         | tr     |       |          |
|                         |      |         | aining |       |          |
|                         |      |         | oc     |       |          |
|                         |      |         | cur?]{ |       |          |
|                         |      |         | .under |       |          |
|                         |      |         | line}* |       |          |
+-------------------------+------+---------+--------+-------+----------+
|                         | [No] | [Ye     | Less   | Once  | More     |
|                         | {.un | s]{.und | Than   | Per   | Than     |
|                         | derl | erline} |        |       |          |
|                         | ine} |         | # [On  | [Ye   | # [On    |
|                         |      |         | ce Per | ar]{. | ce Per Y |
|                         |      |         |  Year] | under | ear]{.un |
|                         |      |         | {.unde | line} | derline} |
|                         |      |         | rline} |       |          |
+-------------------------+------+---------+--------+-------+----------+
| a\. Receive formal      | ~0~  | ~1~    | ~1~   | ~2~  | ~3~     |
| training in conflict    |     | IF YES  |        |       |          |
| resolution?             |      |         |        |       |          |
+-------------------------+------+---------+--------+-------+----------+
| b\. Receive formal      | ~0~  | ~1~    | ~1~   | ~2~  | ~3~     |
| training about cultural |     | IF YES  |        |       |          |
| or language             |      |         |        |       |          |
| differences?            |      |         |        |       |          |
+-------------------------+------+---------+--------+-------+----------+

27\. Does this hospital routinely report information to the public about
its performance in meeting the cultural and language needs of the
service area?

> ~0~  No
>
> ~1~  Yes

**Workforce Racial/Ethnic Composition**

The follow section asks for information about the diversity of your
hospital's workforce. This form is similar to the Equal Employment
Opportunity Report (EEO-1) filled out by the human resources department
of your hospital. If you have a copy of your EEO-1 report, feel free to
send it instead of filling out the form. If you would like assistance
with the categories as they pertain to hospital employees, please see
the Equal Employment Opportunities Commission web site
<http://www.eeoc.gov/eeo1survey/>

29. *What percentage of this hospital's work force is in the following
    racial or ethnic categories?*

<table>
<colgroup>
<col style="width: 17%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="5"><strong>Male</strong></td>
<td colspan="5"><strong>Female</strong></td>
</tr>
<tr class="even">
<td></td>
<td><p>White (non-Hispanic)</p>
<p>A.</p></td>
<td><p>Black (non-Hispanic)</p>
<p>B.</p></td>
<td><p>Hispanic</p>
<p>C.</p></td>
<td><p>Asian or</p>
<p>Pacific Islander</p>
<p>D.</p></td>
<td><p>American Indian or Alaskan Native</p>
<p>E.</p></td>
<td><p>White (non-Hispanic)</p>
<p>F.</p></td>
<td><p>Black (non-Hispanic)</p>
<p>G.</p></td>
<td><p>Hispanic</p>
<p>H.</p></td>
<td><p>Asian or Pacific Islander</p>
<p>I.</p></td>
<td><p>American Indian or Alaskan Native</p>
<p>J</p></td>
</tr>
<tr class="odd">
<td><strong>Officials &amp; Managers</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Professionals</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Technicians</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Sales Workers</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Office &amp; Clerical</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Craft Workers (Skilled)</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Operatives (Semi-Skilled)</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Laborers (Unskilled)</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Service Workers</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td><strong>TOTAL</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Appendix D.4**

**Cultural Competency Assessment Tool for Hospitals (CCATH) Final
Draft**

**Cultural Competency Assessment Tool for Hospitals**

**Draft Item Set**

**Draft for Review Purposes Only- Not for Circulation, Adaptation or
Use**

***Statement of Confidentiality***

Any information that identifies you or your hospital will be kept
confidential and used only for the purposes of this study. RAND will not
release any information that identifies you without your prior consent,
except as required by law.

If you have questions about this study or your participation, please
call the RAND Survey Coordinator, Kelly Sand, at 1-310-393-0411 ext.
7479.

  -----------------------------------------------------------------------
  **Survey Instructions**

  -----------------------------------------------------------------------

**Your hospital has been chosen to participate in the Cultural
Competency Assessment Tool for Hospitals (CCATH). The Office of Minority
Health, a federal agency within the U.S. Department of Health and Human
Services, sponsors this research.** **As you fill out the booklet,
please keep in mind that the information you provide will be kept
confidential. Below are some useful instructions.**

a.  Please answer the questions in this survey booklet about the
    hospital where you received this survey.

b.  This survey covers several topics related to your hospital. Some
    sections may require assistance from other departments.

c.  Please answer each question, unless you are instructed to skip to a
    specific question. When you should skip over a question, you'll see
    an instruction that looks like this:

> **Is today Tuesday?**

~1~ Yes

> ~2~ No *IF NO, Go to Question 1*

d.  If you have any questions or need more information please call the
    RAND Survey Coordinator, Kelly Sand, at 1-310-393-0411, extension
    7479.

e.  When you have completed this survey booklet, please use the
    postage-paid envelope to return it to:

RAND

Attn: Kelly Sand

1700 Main Street

PO Box 2138

Santa Monica, CA 90407-2138

**Table of Contents**

### 

Section A: Culturally Competent Care 6

Section B: Human Resource Management 9

Section C: Translation and Interpreters 12

Section D: Leadership, Strategy, & Climate 16

Section E: Workforce Racial/Ethnic Composition 22

Culturally Competent Care

This first section consists of questions about language and cultural
needs of the in-patient populations receiving care at your hospital.
Potential respondents for this section consist of Directors of Patient
Relations and Vice-Presidents of Nursing.

***1. Does the Hospital: (Check One Box in Each Row)***

  ---------------------------------------------- ------------------ --------------------------- ---------------------------
                                                 [No]{.underline}   Yes, less than half of the  Yes, half or more of the
                                                                    [departments]{.underline}   [departments]{.underline}

  a\. Identify cultural and language needs of    ~1~               ~2~                        ~3~ 
  in-patients in the admission screening?                                                       

  b\. Consider cultural and language needs       ~1~               ~2~                        ~3~ 
  during the discharge planning?                                                                

  c\. Accommodate the ethnic/cultural dietary    ~1~               ~2~                        ~3~ 
  preferences of in-patients?                                                                   

  d\. Tailor patient education materials for     ~1~               ~2~                        ~3~ 
  different cultural and language groups?                                                       

  e\. Tailor patient clinical assessments for    ~1~               ~2~                        ~3~ 
  different cultural and language groups?                                                       
  ---------------------------------------------- ------------------ --------------------------- ---------------------------

2\. Does this hospital collect any ethnicity or racial data on
individuals receiving in-patient services?

> ~1~  No
>
> ~2~  Yes

3\. What percentage of this hospital\'s in-patient population is in the
following racial or ethnic categories? 

> (Check One Box in Each Line)

+-------------------------+-----+------+------+------+-------+-------+
|                         | [No | [    | [    | > [1 | [     | More  |
|                         | n]{ | 1% - | 6% - | 6% - | 26% - | Than  |
|                         | .un | 5%]  | 15%] | >    | 5     | [5    |
|                         | der | {.un | {.un | 25%] | 0%]{. | 0%]{. |
|                         | lin | derl | derl | {.un | under | under |
|                         | e}e | ine} | ine} | derl | line} | line} |
|                         |     |      |      | ine} |       |       |
+-------------------------+-----+------+------+------+-------+-------+
| a\. Hispanic or Latino  | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
|                         |    |     |     |     |       |       |
+-------------------------+-----+------+------+------+-------+-------+
| Non-Hispanic:           | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
|                         |    |     |     |     |       |       |
+-------------------------+-----+------+------+------+-------+-------+
| b\. Asian or Pacific    | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
| Islander                |    |     |     |     |       |       |
+-------------------------+-----+------+------+------+-------+-------+
| c\. American Indian or  | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
| Alaska Native           |    |     |     |     |       |       |
+-------------------------+-----+------+------+------+-------+-------+
| d\. Black or African    | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
| American                |    |     |     |     |       |       |
+-------------------------+-----+------+------+------+-------+-------+
| f\. White               | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
|                         |    |     |     |     |       |       |
+-------------------------+-----+------+------+------+-------+-------+
| g\. Other (please       | ~1~ | ~2~  | ~3~  | ~4~  | ~5~  | ~6~  |
| specify)                |    |     |     |     |       |       |
| \_\_\_\                 |     |      |      |      |       |       |
| _\_\_\_\_\_\_\_\_\_\_\_ |     |      |      |      |       |       |
+-------------------------+-----+------+------+------+-------+-------+

4\. Does this hospital collect data on the preferred language for
individuals receiving in-patient services?

> ~1~  No
>
> ~2~  Yes

5\. What percentage of this hospital\'s in-patient population is in the
following language categories?

***(Check One Box in Each Line)***

  ---------------------------------------- ----------------- ------------------ ------------------ ------------------ -------------------
                                           [1% -             [6% -              [16% -             [26% -             More Than
                                           5%]{.underline}   15%]{.underline}   25%]{.underline}   50%]{.underline}   [50%]{.underline}

  a\. English                              ~1~              ~2~               ~3~               ~4~               ~5~ 

  b\. Spanish                              ~1~              ~2~               ~3~               ~4~               ~5~ 

  c\. Chinese                              ~1~              ~2~               ~3~               ~4~               ~5~ 

  d\. French                               ~1~              ~2~               ~3~               ~4~               ~5~ 

  e\. German                               ~1~              ~2~               ~3~               ~4~               ~5~ 

  f\. Tagalog                              ~1~              ~2~               ~3~               ~4~               ~5~ 

  g\. Other (please specify)               ~1~              ~2~               ~3~               ~4~               ~5~ 
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              

  h\. Other (please specify)               ~1~              ~2~               ~3~               ~4~               ~5~ 
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              

  I. Other (please specify)                ~1~              ~2~               ~3~               ~4~               ~5~ 
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              
  ---------------------------------------- ----------------- ------------------ ------------------ ------------------ -------------------

> **Human Resource Management**

This next section consists of questions about staff benefits, available
training, and staff satisfaction. A human resources representative may
be the best person to fill out this section.

6\. Which of the following benefits are available to staff? *[Which
types of staff are eligible for these benefits?]{.underline}*

+-----------------------+---+---------+-------+---------+----------+
|                       | [ | [Ye     | Top   | Dep     | N        |
|                       | N | s]{.und |       | artment | ursing,\ |
|                       | o | erline} | [Man  | Heads/  | Allied   |
|                       | ] |         | ageme |         | Health\  |
|                       | { |         | nt]{. | # [Sup  | [or      |
|                       | . |         | under | ervisor | Support  |
|                       | u |         | line} | s]{.und | St       |
|                       | n |         |       | erline} | aff]{.un |
|                       | d |         |       |         | derline} |
|                       | e |         |       |         |          |
|                       | r |         |       |         |          |
|                       | l |         |       |         |          |
|                       | i |         |       |         |          |
|                       | n |         |       |         |          |
|                       | e |         |       |         |          |
|                       | } |         |       |         |          |
+-----------------------+---+---------+-------+---------+----------+
| a\. Formal mentoring  | ~ | ~1~    | ~1~  | ~2~    | ~3~     |
| program               | 0 | IF YES  |       |         |          |
|                       | ~ |         |       |         |          |
|                       |  |         |       |         |          |
+-----------------------+---+---------+-------+---------+----------+
| b\. Management        | ~ | ~1~    | ~1~  | ~2~    | ~3~     |
| training              | 0 | IF YES  |       |         |          |
|                       | ~ |         |       |         |          |
|                       |  |         |       |         |          |
+-----------------------+---+---------+-------+---------+----------+
| c\. Tuition           | ~ | ~1~    | ~1~  | ~2~    | ~3~     |
| assistance or tuition | 0 | IF YES  |       |         |          |
| reimbursement for     | ~ |         |       |         |          |
| ongoing education     |  |         |       |         |          |
+-----------------------+---+---------+-------+---------+----------+
| d\. Personal          | ~ | ~1~    | ~1~  | ~2~    | ~3~     |
| counseling or         | 0 | IF YES  |       |         |          |
| employee\             | ~ |         |       |         |          |
| assistance programs   |  |         |       |         |          |
+-----------------------+---+---------+-------+---------+----------+
| e\. Flexible benefits | ~ | ~1~    | ~1~  | ~2~    | ~3~     |
| such as domestic      | 0 | IF YES  |       |         |          |
| partner benefits,     | ~ |         |       |         |          |
| family illness,       |  |         |       |         |          |
| death, and personal   |   |         |       |         |          |
| leave policies that   |   |         |       |         |          |
| accommodate           |   |         |       |         |          |
| alternative           |   |         |       |         |          |
| definitions of family |   |         |       |         |          |
+-----------------------+---+---------+-------+---------+----------+
| f\. Affinity          | ~ | ~1~    | ~1~  | ~2~    | ~3~     |
| (networking) groups   | 0 | IF YES  |       |         |          |
| for racial/ethnic     | ~ |         |       |         |          |
| minority staff        |  |         |       |         |          |
+-----------------------+---+---------+-------+---------+----------+
| g\. Work/life balance | ~ | ~1~    | ~1~  | ~2~    | ~3~     |
| programs such as      | 0 | IF YES  |       |         |          |
| flextime, job sharing | ~ |         |       |         |          |
| or telecommuting,     |  |         |       |         |          |
| child or elder care   |   |         |       |         |          |
+-----------------------+---+---------+-------+---------+----------+
| h\. Compensatory pay  | ~ | ~1~    | ~1~  | ~2~    | ~3~     |
| for bilingual staff   | 0 | IF YES  |       |         |          |
|                       | ~ |         |       |         |          |
|                       |  |         |       |         |          |
+-----------------------+---+---------+-------+---------+----------+

7\. Does this hospital track changes in the race or ethnicity of its
work force?

> ~0~  No
>
> ~1~  Yes

8\. Does this hospital conduct employee satisfaction surveys?

> ~0~  No IF NO, Go to Question 10
>
> ~1~  Yes

9\. Does the employee satisfaction survey include measures of diversity
climate?

> ~0~  No
>
> ~1~  Yes

10\. Does this hospital have a formal and ongoing training program on
cultural and language diversity? Note: This may consist of either a
stand-alone training program or several training components integrated
into other types of training.

> ~0~  No IF NO, Go to Question 13 (Translation and Interpreters
> Section)
>
> ~1~  Yes

11\. Is the cultural and language diversity training program voluntary
or mandatory? Note: If your hospital has both voluntary and mandatory
programs, then mark both categories below.

> ~0~  Voluntary Approximately what percentage of the hospital
> administration attend the voluntary training? \_\_\_\_\_%
>
> Approximately what percentage of the hospital non-clinical staff
> attend the voluntary training? \_\_\_\_\_%
>
> Approximately what percentage of the hospital clinical staff
> (excluding physicians)attend the voluntary training?\_\_\_\_%
>
> Approximately what percentage of the hospital physicians attend the
> voluntary training? \_\_\_\_\_%
>
> ~1~  Mandatory Approximately what percentage of the hospital
> administration attend the voluntary training? \_\_\_\_\_%
>
> Approximately what percentage of the hospital non-clinical staff
> attend the voluntary training? \_\_\_\_\_%
>
> Approximately what percentage of the hospital clinical staff
> (excluding physicians)attend the voluntary training?\_\_\_\_%
>
> Approximately what percentage of the hospital physicians attend the
> voluntary training? \_\_\_\_\_%

######## 

12\. Is it a stand alone training program, or is cultural and language
diversity training integrated into other types of training?

> ~1~  Stand alone only
>
> ~2~  Integrated with other training only
>
> ~3~  Both stand alone and integrated with other training

**Interpreters and Translators**

The following section pertains to interpreting and translating services.
Examples of people who may have the necessary information to fill out
this section are Coordinators of Interpreter Services, Directors of
Patient Relations and Managers of Language Resources. **Please note that
an *interpreter* translates from one language to another
[orally]{.underline}. A *translator* translates [written]{.underline}
materials from the source language into another language.**

13\. Are interpreter services available for in-patients in the following
languages?

***If Yes: [Which services are available? (Mark All That
Apply)]{.underline}***

+-------------------------+----+----+--------+--------+--------+-------+
|                         | [N | [  | Bil    | Face-t | Face-t | Tele  |
|                         | o] | Ye | ingual | o-Face | o-Face | phone |
|                         | {. | s] | Staff  | Profes |        | I     |
|                         | un | {. |        | sional | Vol    | nterp |
|                         | de | un | [as    | [I     | unteer | reter |
|                         | rl | de | i      | nterpr | [I     |       |
|                         | in | rl | nterpr | eters] | nterpr | [S    |
|                         | e} | in | eters] | {.unde | eters] | ervic |
|                         |    | e} | {.unde | rline} | {.unde | es]{. |
|                         |    |    | rline} |        | rline} | under |
|                         |    |    |        |        |        | line} |
+-------------------------+----+----+--------+--------+--------+-------+
| a\. Spanish             | ~  | ~  | ~1~   | ~2~   | ~3~   | ~4~  |
|                         | 0~ | 1~ |        |        |        |       |
|                         |   |   |        |        |        |       |
+-------------------------+----+----+--------+--------+--------+-------+
| b\. Chinese             | ~  | ~  | ~1~   | ~2~   | ~3~   | ~4~  |
|                         | 0~ | 1~ |        |        |        |       |
|                         |   |   |        |        |        |       |
+-------------------------+----+----+--------+--------+--------+-------+
| d\. French              | ~  | ~  | ~1~   | ~2~   | ~3~   | ~4~  |
|                         | 0~ | 1~ |        |        |        |       |
|                         |   |   |        |        |        |       |
+-------------------------+----+----+--------+--------+--------+-------+
| e\. German              | ~  | ~  | ~1~   | ~2~   | ~3~   | ~4~  |
|                         | 0~ | 1~ |        |        |        |       |
|                         |   |   |        |        |        |       |
+-------------------------+----+----+--------+--------+--------+-------+
| f\. Tagalong            | ~  | ~  | ~1~   | ~2~   | ~3~   | ~4~  |
|                         | 0~ | 1~ |        |        |        |       |
|                         |   |   |        |        |        |       |
+-------------------------+----+----+--------+--------+--------+-------+
| g\. Other (please       |    |    | ~1~   | ~2~   | ~3~   | ~4~  |
| specify)                |    |    |        |        |        |       |
| \_\_\                   |    |    |        |        |        |       |
| _\_\_\_\_\_\_\_\_\_\_\_ |    |    |        |        |        |       |
+-------------------------+----+----+--------+--------+--------+-------+
| h\. Other (please       |    |    | ~1~   | ~2~   | ~3~   | ~4~  |
| specify)                |    |    |        |        |        |       |
| \_\_\                   |    |    |        |        |        |       |
| _\_\_\_\_\_\_\_\_\_\_\_ |    |    |        |        |        |       |
+-------------------------+----+----+--------+--------+--------+-------+
| I. Other (please        |    |    | ~1~   | ~2~   | ~3~   | ~4~  |
| specify)                |    |    |        |        |        |       |
| \_\_\                   |    |    |        |        |        |       |
| _\_\_\_\_\_\_\_\_\_\_\_ |    |    |        |        |        |       |
+-------------------------+----+----+--------+--------+--------+-------+

14\. Does this hospital include information on the availability of
interpreter services in marketing and community outreach initiatives
such as television advertising, marketing brochures, and health fairs?

> ~0~  No
>
> ~1~  Yes

15\. Does this hospital have a written policy and procedures about the:

  -------------------------------------------------- ------------------ -------------------
                                                     [No]{.underline}   [Yes]{.underline}

  a\. Use of bilingual staff as interpreters?        ~0~               ~1~ 

  b\. Use of face-to-face professional interpreters? ~0~               ~1~ 

  c\. Use of face-to-face volunteer interpreters?    ~0~               ~1~ 

  d\. Use of telephone interpreter services?         ~0~               ~1~ 

  e\. Use of family or friends as interpreters?      ~0~               ~1~ 
  -------------------------------------------------- ------------------ -------------------

16\. Does the hospital require an assessment of: *[If Yes: Who conducts
the interpreter assessment?]{.underline}*

(Mark All That Apply)

  ----------------------------- ------------------ ------------------- -- -------------------- --------------------------
                                [No]{.underline}   [Yes]{.underline}      [In-house            Vendor or
                                                                          Staff]{.underline}   [Contractor]{.underline}

  a\. Interpreter fluency in    ~0~               ~1~                   ~1~                 ~2~ 
  translating medical\                                                                         
  terms and procedures?                                                                        

  b\. Interpreter accuracy and  ~0~               ~1~                   ~1~                 ~2~ 
  completeness?                                                                                
  ----------------------------- ------------------ ------------------- -- -------------------- --------------------------

17\. Does this hospital provide translated written materials for
in-patient populations in languages other than English?

~0~  No Go to Question 19

~1~  Yes Continue

18a. What types of written materials does this hospital routinely
provide to in-patients in languages other than English?

<table style="width:100%;">
<colgroup>
<col style="width: 19%" />
<col style="width: 6%" />
<col style="width: 12%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 9%" />
<col style="width: 13%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td colspan="7"><em><u>In what languages are written materials
translated?</u></em></td>
</tr>
<tr class="even">
<td></td>
<td><u>No</u></td>
<td><u>Yes</u></td>
<td><u>Spanish</u></td>
<td><u>Chinese</u></td>
<td><u>French</u></td>
<td><u>German</u></td>
<td><u>Tagalog</u></td>
<td><p><u>Other</u></p>
<p>(please specify)</p>
<p>_______</p></td>
<td><p><u>Othe</u>r</p>
<p>(please specify)</p>
<p>___________</p></td>
</tr>
<tr class="odd">
<td>a. Informed consent statements</td>
<td><sub>0</sub> </td>
<td><sub>1</sub>  IF YES</td>
<td><sub>1</sub> </td>
<td><sub>2</sub> </td>
<td><sub>3</sub> </td>
<td><sub>4</sub> </td>
<td><sub>5</sub> </td>
<td><sub>6</sub> </td>
<td><sub>7</sub> </td>
</tr>
<tr class="even">
<td>b. Medication instructions</td>
<td><sub>0</sub> </td>
<td><sub>1</sub>  IF YES</td>
<td><sub>1</sub> </td>
<td><sub>2</sub> </td>
<td><sub>3</sub> </td>
<td><sub>4</sub> </td>
<td><sub>5</sub> </td>
<td><sub>6</sub> </td>
<td><sub>7</sub> </td>
</tr>
<tr class="odd">
<td>c. Discharge planning instructions</td>
<td><sub>0</sub> </td>
<td><sub>1</sub>  IF YES</td>
<td><sub>1</sub> </td>
<td><sub>2</sub> </td>
<td><sub>3</sub> </td>
<td><sub>4</sub> </td>
<td><sub>5</sub> </td>
<td><sub>6</sub> </td>
<td><sub>7</sub> </td>
</tr>
<tr class="even">
<td>d. Patient advance directives</td>
<td><sub>0</sub> </td>
<td><sub>1</sub>  IF YES</td>
<td><sub>1</sub> </td>
<td><sub>2</sub> </td>
<td><sub>3</sub> </td>
<td><sub>4</sub> </td>
<td><sub>5</sub> </td>
<td><sub>6</sub> </td>
<td><sub>7</sub> </td>
</tr>
<tr class="odd">
<td>e. Health education material</td>
<td><sub>0</sub> </td>
<td><sub>1</sub>  IF YES</td>
<td><sub>1</sub> </td>
<td><sub>2</sub> </td>
<td><sub>3</sub> </td>
<td><sub>4</sub> </td>
<td><sub>5</sub> </td>
<td><sub>6</sub> </td>
<td><sub>7</sub> </td>
</tr>
</tbody>
</table>

18b. How is the translation done?

***(Mark All That Apply)***

  ----------------------- -------------------------- ------------------------ -------------------------
  [In-house               Vendor or                  [Software]{.underline}   Software checked by
  Staff]{.underline}      [Contractor]{.underline}                            in-house staff, [vendor,
                                                                              or
                                                                              contractor]{.underline}

  ~1~                    ~2~                       ~3~                     ~4~ 

  ~1~                    ~2~                       ~3~                     ~4~ 
  ----------------------- -------------------------- ------------------------ -------------------------

19\. Does this hospital post signs providing directions in languages
other than English?

> ~0~  No
>
> ~1~  Yes

####### Leadership, Strategy, & Climate

> The following section is about this hospital's strategic goals, and
> the language and cultural needs of the service area. Potential
> respondents for this section include the Vice-President for
> Planning/Business Development and the Chief Operating Officer.

20\. Does this hospital's statement of strategic goals include:

***(Check One Box in Each Row)***

  ------------------------------------------------------ ------------------ -------------------
                                                         [No]{.underline}   [Yes]{.underline}

  a\. Specific language about [recruitment]{.underline}  ~0~               ~1~ 
  of a culturally diverse work force?                                       

  b\. Specific language about [retention]{.underline} of ~0~               ~1~ 
  a culturally diverse work force?                                          

  c\. Specific language about the provision of           ~0~               ~1~ 
  culturally appropriate patient services?                                  
  ------------------------------------------------------ ------------------ -------------------

21\. During the strategic planning process, does this hospital routinely
assess achievement of its cultural diversity goals?

> ~0~  No
>
> ~1~  Yes

22\. Is there a person, office or committee who has dedicated
responsibility for promoting this hospital's cultural diversity goals?

> ~0~  No
>
> ~1~  Yes
>
> If yes, which of the following are in place? ***(Mark All That
> Apply)***
>
> ~1~  Dedicated Diversity Department
>
> ~2~  Diversity Action or Advisory Committee or Council
>
> ~3~  Full-time Dedicated Diversity Administrator: if yes to Dedicated
> Diversity Administrator, to whom does this administrator report
>
> ~1~  CEO
>
> ~2~  Direct report to CEO
>
> ~3~  Head of Human Resources
>
> ~4~  Head of Nursing Services
>
> ~5~  Other: Please specify \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

23\. Are the following assessments conducted at least once each year?

+-------------------------+------+---------+------+------+---------+---+
|                         |      |         | ##   |      |         |   |
|                         |      |         | ###  |      |         |   |
|                         |      |         | If Y |      |         |   |
|                         |      |         | es:  |      |         |   |
|                         |      |         | Are  |      |         |   |
|                         |      |         | resu |      |         |   |
|                         |      |         | lts  |      |         |   |
|                         |      |         | used |      |         |   |
|                         |      |         |  in  |      |         |   |
|                         |      |         | qual |      |         |   |
|                         |      |         | ity  |      |         |   |
|                         |      |         | impr |      |         |   |
|                         |      |         | ovem |      |         |   |
|                         |      |         | ent? |      |         |   |
+-------------------------+------+---------+------+------+---------+---+
|                         | [No] | [Ye     | #    | [    | #       | # |
|                         | {.un | s]{.und |      | Yes] |         |   |
|                         | derl | erline} | #    | {.un |         |   |
|                         | ine} |         | [No] | derl |         |   |
|                         |      |         | {.un | ine} |         |   |
|                         |      |         | derl |      |         |   |
|                         |      |         | ine} |      |         |   |
+-------------------------+------+---------+------+------+---------+---+
| a\. Accessibility of    | ~0~  | ~1~    | ~1~  | ~2~  |         |   |
| interpreter services    |     | IF YES  |     |     |         |   |
+-------------------------+------+---------+------+------+---------+---+
| b\. Racial/ethnic       | ~0~  | ~1~    | ~1~  | ~2~  |         |   |
| differences in          |     | IF YES  |     |     |         |   |
| in-patient service use  |      |         |      |      |         |   |
+-------------------------+------+---------+------+------+---------+---+
| c\. Racial/ethnic       | ~0~  | ~1~    | ~1~  | ~2~  |         |   |
| differences in          |     | IF YES  |     |     |         |   |
| in-patient assessments  |      |         |      |      |         |   |
| of care (satisfaction)  |      |         |      |      |         |   |
+-------------------------+------+---------+------+------+---------+---+

24\. Does this hospital collect or receive any of the following data on
the [population residing in the service area]{.underline}?

+--------------------------+------+---------+---------+------+---+------+
|                          |      |         | *If     |      |   |      |
|                          |      |         | Yes:    |      |   |      |
|                          |      |         | Are the |      |   |      |
|                          |      |         | results |      |   |      |
|                          |      |         | used in |      |   |      |
|                          |      |         | p       |      |   |      |
|                          |      |         | rogram* |      |   |      |
|                          |      |         |         |      |   |      |
|                          |      |         | *[and   |      |   |      |
|                          |      |         | service |      |   |      |
|                          |      |         | pl      |      |   |      |
|                          |      |         | anning? |      |   |      |
|                          |      |         | ]{.unde |      |   |      |
|                          |      |         | rline}* |      |   |      |
+--------------------------+------+---------+---------+------+---+------+
|                          | [No] | [Ye     | #       | [    | # | #    |
|                          | {.un | s]{.und |         | Yes] |   |      |
|                          | derl | erline} | # [N    | {.un |   |      |
|                          | ine} |         | o]{.und | derl |   |      |
|                          |      |         | erline} | ine} |   |      |
+--------------------------+------+---------+---------+------+---+------+
| a\. Race/ethnicity       | ~0~  | ~1~    | ~1~    | ~2~  |   |      |
|                          |     | IF YES  |         |     |   |      |
+--------------------------+------+---------+---------+------+---+------+
| b\. Languages spoken     | ~0~  | ~1~    | ~1~    | ~2~  |   |      |
|                          |     | IF YES  |         |     |   |      |
+--------------------------+------+---------+---------+------+---+------+
| c\. Income levels        | ~0~  | ~1~    | ~1~    | ~2~  |   |      |
|                          |     | IF YES  |         |     |   |      |
+--------------------------+------+---------+---------+------+---+------+
| d\. Education levels     | ~0~  | ~1~    | ~1~    | ~2~  |   |      |
|                          |     | IF YES  |         |     |   |      |
+--------------------------+------+---------+---------+------+---+------+
| e\. Health risks profile | ~0~  | ~1~    | ~1~    | ~2~  |   |      |
| (for diseases or         |     | IF YES  |         |     |   |      |
| conditions that          |      |         |         |      |   |      |
| disproportionately       |      |         |         |      |   |      |
| affect a particular      |      |         |         |      |   |      |
| racial/ethnic/gender     |      |         |         |      |   |      |
| demographic such as      |      |         |         |      |   |      |
| African American men,    |      |         |         |      |   |      |
| Latino women, or         |      |         |         |      |   |      |
| individuals of Jewish    |      |         |         |      |   |      |
| ethnicity)               |      |         |         |      |   |      |
+--------------------------+------+---------+---------+------+---+------+
| g\. Utilization of       | ~0~  | ~1~    | ~1~    | ~2~  |   |      |
| health screening         |     | IF YES  |         |     |   |      |
| services\                |      |         |         |      |   |      |
| (mammograms, prostate    |      |         |         |      |   |      |
| screening exams, PAP     |      |         |         |      |   |      |
| smears)                  |      |         |         |      |   |      |
+--------------------------+------+---------+---------+------+---+------+

+-----------------------+---+---------+---+---+------+-----+------+------+
| 25\. Are community    |   |         |   | * |      |     |      |      |
| representatives       |   |         |   | I |      |     |      |      |
| routinely involved in |   |         |   | f |      |     |      |      |
| the...                |   |         |   | Y |      |     |      |      |
|                       |   |         |   | e |      |     |      |      |
|                       |   |         |   | s |      |     |      |      |
|                       |   |         |   | : |      |     |      |      |
|                       |   |         |   | H |      |     |      |      |
|                       |   |         |   | o |      |     |      |      |
|                       |   |         |   | w |      |     |      |      |
|                       |   |         |   | i |      |     |      |      |
|                       |   |         |   | s |      |     |      |      |
|                       |   |         |   | t |      |     |      |      |
|                       |   |         |   | h |      |     |      |      |
|                       |   |         |   | e |      |     |      |      |
|                       |   |         |   | i |      |     |      |      |
|                       |   |         |   | r |      |     |      |      |
|                       |   |         |   | i |      |     |      |      |
|                       |   |         |   | n |      |     |      |      |
|                       |   |         |   | p |      |     |      |      |
|                       |   |         |   | u |      |     |      |      |
|                       |   |         |   | t |      |     |      |      |
|                       |   |         |   | o |      |     |      |      |
|                       |   |         |   | b |      |     |      |      |
|                       |   |         |   | t |      |     |      |      |
|                       |   |         |   | a |      |     |      |      |
|                       |   |         |   | i |      |     |      |      |
|                       |   |         |   | n |      |     |      |      |
|                       |   |         |   | e |      |     |      |      |
|                       |   |         |   | d |      |     |      |      |
|                       |   |         |   | ? |      |     |      |      |
|                       |   |         |   | \ |      |     |      |      |
|                       |   |         |   | * |      |     |      |      |
|                       |   |         |   | * |      |     |      |      |
|                       |   |         |   | ( |      |     |      |      |
|                       |   |         |   | M |      |     |      |      |
|                       |   |         |   | A |      |     |      |      |
|                       |   |         |   | R |      |     |      |      |
|                       |   |         |   | K |      |     |      |      |
|                       |   |         |   | A |      |     |      |      |
|                       |   |         |   | L |      |     |      |      |
|                       |   |         |   | L |      |     |      |      |
|                       |   |         |   | T |      |     |      |      |
|                       |   |         |   | H |      |     |      |      |
|                       |   |         |   | A |      |     |      |      |
|                       |   |         |   | T |      |     |      |      |
|                       |   |         |   | A |      |     |      |      |
|                       |   |         |   | P |      |     |      |      |
|                       |   |         |   | P |      |     |      |      |
|                       |   |         |   | L |      |     |      |      |
|                       |   |         |   | Y |      |     |      |      |
|                       |   |         |   | ) |      |     |      |      |
|                       |   |         |   | * |      |     |      |      |
|                       |   |         |   | * |      |     |      |      |
|                       |   |         |   | * |      |     |      |      |
+-----------------------+---+---------+---+---+------+-----+------+------+
|                       | [ | [Ye     | # |   | C    | #   | #    | # P  |
|                       | N | s]{.und |   |   | ommu |  Wr |  Tel | erso |
|                       | o | erline} | F |   | nity | itt | epho | nal  |
|                       | ] |         | o |   | [M   | en  | ne [ |      |
|                       | { |         | c |   | eeti | [Su | Surv | #    |
|                       | . |         | u |   | ngs] | rve | eys] | [Int |
|                       | u |         | s |   | {.un | ys] | {.un | ervi |
|                       | n |         |   |   | derl | {.u | derl | ews] |
|                       | d |         | [ |   | ine} | nde | ine} | {.un |
|                       | e |         | G |   |      | rli |      | derl |
|                       | r |         | r |   |      | ne} |      | ine} |
|                       | l |         | o |   |      |     |      |      |
|                       | i |         | u |   |      |     |      |      |
|                       | n |         | p |   |      |     |      |      |
|                       | e |         | s |   |      |     |      |      |
|                       | } |         | ] |   |      |     |      |      |
|                       |   |         | { |   |      |     |      |      |
|                       |   |         | . |   |      |     |      |      |
|                       |   |         | u |   |      |     |      |      |
|                       |   |         | n |   |      |     |      |      |
|                       |   |         | d |   |      |     |      |      |
|                       |   |         | e |   |      |     |      |      |
|                       |   |         | r |   |      |     |      |      |
|                       |   |         | l |   |      |     |      |      |
|                       |   |         | i |   |      |     |      |      |
|                       |   |         | n |   |      |     |      |      |
|                       |   |         | e |   |      |     |      |      |
|                       |   |         | } |   |      |     |      |      |
+-----------------------+---+---------+---+---+------+-----+------+------+
| a\. Planning and      | ~ | ~1~    | ~ |   | ~2~  | ~3~ | ~4~  | ~3~  |
| design of in-patient  | 0 | IF YES  | 1 |   |     |    |     |     |
| services for          | ~ |         | ~ |   |      |     |      |      |
| culturally diverse    |  |         |  |   |      |     |      |      |
| populations?          |   |         |   |   |      |     |      |      |
+-----------------------+---+---------+---+---+------+-----+------+------+
| b\. Evaluation of     | ~ | ~1~    | ~ |   | ~2~  | ~3~ | ~4~  | ~3~  |
| existing services for | 0 | IF YES  | 1 |   |     |    |     |     |
| culturally diverse    | ~ |         | ~ |   |      |     |      |      |
| populations?          |  |         |  |   |      |     |      |      |
+-----------------------+---+---------+---+---+------+-----+------+------+

26\. Do the staff involved in the formal complaint and grievance
process:

+-------------------------+------+---------+--------+-------+----------+
|                         |      |         | *[How  |       |          |
|                         |      |         | often  |       |          |
|                         |      |         | does   |       |          |
|                         |      |         | tr     |       |          |
|                         |      |         | aining |       |          |
|                         |      |         | oc     |       |          |
|                         |      |         | cur?]{ |       |          |
|                         |      |         | .under |       |          |
|                         |      |         | line}* |       |          |
+-------------------------+------+---------+--------+-------+----------+
|                         | [No] | [Ye     | Less   | Once  | More     |
|                         | {.un | s]{.und | Than   | Per   | Than     |
|                         | derl | erline} |        |       |          |
|                         | ine} |         | # [On  | [Ye   | # [On    |
|                         |      |         | ce Per | ar]{. | ce Per Y |
|                         |      |         |  Year] | under | ear]{.un |
|                         |      |         | {.unde | line} | derline} |
|                         |      |         | rline} |       |          |
+-------------------------+------+---------+--------+-------+----------+
| a\. Receive formal      | ~0~  | ~1~    | ~1~   | ~2~  | ~3~     |
| training in conflict    |     | IF YES  |        |       |          |
| resolution?             |      |         |        |       |          |
+-------------------------+------+---------+--------+-------+----------+
| b\. Receive formal      | ~0~  | ~1~    | ~1~   | ~2~  | ~3~     |
| training about cultural |     | IF YES  |        |       |          |
| or language             |      |         |        |       |          |
| differences?            |      |         |        |       |          |
+-------------------------+------+---------+--------+-------+----------+

27\. Does this hospital report information to the community at least
once per year about its performance in meeting the cultural and language
needs of the service area? Note: This does not include EEO reporting to
government agencies on workforce demographics.

> ~0~  No
>
> ~1~  Yes

28\. About how much time was required to complete this survey:
\_\_\_\_\_\_\_\_minutes

**Workforce Racial/Ethnic Composition**

The follow section asks for information about the diversity of your
hospital's workforce. This form is similar to the Equal Employment
Opportunity Report (EEO-1) filled out by the human resources department
of your hospital. If you have a copy of your EEO-1 report, feel free to
send it instead of filling out the form. If you would like assistance
with the categories as they pertain to hospital employees, please see
the Equal Employment Opportunities Commission web site
<http://www.eeoc.gov/eeo1survey/>

29. *What percentage of this hospital's work force is in the following
    racial or ethnic categories?*

<table>
<colgroup>
<col style="width: 19%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 9%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="5"><strong>Male</strong></td>
<td colspan="5"><strong>Female</strong></td>
</tr>
<tr class="even">
<td></td>
<td><blockquote>
<p>White (non-Hispanic)</p>
<p>A.</p>
</blockquote></td>
<td><blockquote>
<p>Black (non-Hispanic)</p>
<p>B.</p>
</blockquote></td>
<td><blockquote>
<p>Hispanic</p>
<p>C.</p>
</blockquote></td>
<td><p>Asian or</p>
<p>Pacific Islander</p>
<p>D.</p></td>
<td><blockquote>
<p>American Indian or Alaskan Native</p>
<p>E.</p>
</blockquote></td>
<td><p>White (non-Hispanic)</p>
<p>F.</p></td>
<td><p>Black (non-Hispanic)</p>
<p>G.</p></td>
<td><p>Hispanic</p>
<p>H.</p></td>
<td><p>Asian or Pacific Islander</p>
<p>I.</p></td>
<td><p>American Indian or Alaskan Native</p>
<p>J</p></td>
</tr>
<tr class="odd">
<td><strong>Officials &amp; Managers</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Professionals</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Technicians</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Sales Workers</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Office &amp; Clerical</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Craft Workers (Skilled)</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Operatives (Semi-skilled)</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Laborers (Unskilled)</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Service Workers</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>TOTAL</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

Date of EEO-1 report used: \_\_\_\_\_\_\_\_\_,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Month Year