**Appendix B**

**CLAS Standards and CCATH Domains**

+-----------------------------------+----------------------------------+
| **Standards**                     | **Domains**                      |
+===================================+==================================+
| # *Culturally Competent Care*     | #                                |
+-----------------------------------+----------------------------------+
| 1\. Health care organizations     | 1.  Organizational               |
| should ensure that                |     Climate/Culture (Patient     |
| patients/consumers receive from   |     Care)                        |
| all staff members effective,      |                                  |
| understandable and respectful     | 2.  Service Delivery             |
| care that is provided in a manner |                                  |
| compatible with their cultural    | 3.  Physical Environment/Food    |
| health beliefs and practices and  |     Services                     |
| preferred language.               |                                  |
|                                   | 4.  Staff Accountability         |
|                                   |                                  |
|                                   | 5.  Patient Policies             |
|                                   |                                  |
|                                   | .                                |
+-----------------------------------+----------------------------------+
| 2\. Health care organizations     | 1.  Leadership/Organizational    |
| should implement strategies to    |     Climate (Workforce)          |
| recruit, retain and promote at    |                                  |
| all levels of the organization a  | 2.  Human Resource Policies      |
| diverse staff and leadership that |                                  |
| are representative of the         | 3.  Workforce Representation     |
| demographic characteristics of    |                                  |
| the service area.                 | 4.  Workforce Recruitment        |
|                                   |     Practices                    |
|                                   |                                  |
|                                   | 5.  Workforce                    |
|                                   |     Retention/Promotion          |
|                                   |     Practices                    |
+-----------------------------------+----------------------------------+
| 3\. Health care organizations     | 1.  Organizational               |
| should ensure that staff at all   |     Commitment/Climate           |
| levels and across all disciplines |     (Diversity Training)         |
| receive ongoing education and     |                                  |
| training in culturally and        | 2.  Diversity Leadership         |
| linguistically appropriate        |     Training for                 |
| service delivery.                 |     Executives/Management        |
|                                   |                                  |
|                                   | 3.  Diversity Training for Staff |
|                                   |     and Clinicians               |
|                                   |                                  |
|                                   | 4                                |
|                                   | .  Content/Methods/Effectiveness |
|                                   |     of Diversity Training        |
|                                   |                                  |
|                                   | 5.  Training Related to Language |
|                                   |     Services                     |
+-----------------------------------+----------------------------------+
| *Language Access Services*        |                                  |
+-----------------------------------+----------------------------------+
| 4\. Health care organizations     | 1.  Language Assistance Needs    |
| must offer and provide language   |                                  |
| assistance services, including    | 2.  Policies (Language Services) |
| bilingual staff and interpreter   |                                  |
| services, at no cost to each      | 3.  Availability of Language     |
| patient/consumer with limited     |     Services                     |
| English proficiency at all points |                                  |
| of contact, in a timely manner    | 4.  Staffing for Language        |
| during all hours of operation.    |     Services                     |
|                                   |                                  |
|                                   | 5.  Resources Dedicated to       |
|                                   |     Language Services            |
+-----------------------------------+----------------------------------+
| 5\. Health care organizations     | 1.  Verbal and Written Notices   |
| must offer and provide to         |     on Language Services         |
| patients/consumers in their       |                                  |
| preferred language both verbal    |                                  |
| offers and written notices        |                                  |
| informing them of their right to  |                                  |
| receive language assistance       |                                  |
| services.                         |                                  |
+-----------------------------------+----------------------------------+
| 6\. Health care organizations     | > 1\. Qualifications for         |
| must assure the competence of     | > Interpreters                   |
| language assistance provided to   |                                  |
| limited English proficient        | 2.  Quality Assessment of        |
| patients/consumers by             |     Interpreter Services         |
| interpreters and bilingual staff. |                                  |
| Family and friends should not be  | 3.  Policy on Use of             |
| used to provide interpretation    |     Family/Friends as            |
| services (except on request by    |     Interpreters                 |
| the patient/consumer).            |                                  |
+-----------------------------------+----------------------------------+
| 7\. Health care organizations     | 1.  Availability of Translated   |
| must make available easily        |     Patient Materials            |
| understood patient-related        |                                  |
| materials and post signage in the | 2.  Staffing for Translation     |
| languages of the commonly         |     Services                     |
| encountered groups and/or groups  |                                  |
| represented in the service area.  | 3.  Multilingual Signage         |
+-----------------------------------+----------------------------------+
| # *Organizational Support*        | #                                |
+-----------------------------------+----------------------------------+
| 8\. Health care organizations     | 1.  Organizational Mission       |
| should develop, implement and     |                                  |
| promote a written strategic plan  | 2.  Strategic Plan               |
| that outlines clear goals,        |                                  |
| policies, operational plans and   | 3.  Organizational Structure     |
| management                        |                                  |
| accountability/oversight          | 4.  Management Accountability    |
| mechanisms to provide culturally  |                                  |
| and linguistically appropriate    | 5.  Dedicated Resources          |
| services.                         |                                  |
+-----------------------------------+----------------------------------+
| 9\. Health care organizations     | 1.  Organizational Assessments   |
| should conduct initial and        |     (General)                    |
| ongoing organizational            |                                  |
| self-assessments of CLAS-related  | 2.  Workforce/Staffing           |
| activities and are encouraged to  |     Assessment                   |
| integrate cultural and linguistic |                                  |
| competence-related measures into  | 3.  Service Delivery Assessment  |
| their internal audits,            |                                  |
| performance improvement programs, | 4.  Patient Satisfaction         |
| patient satisfaction assessments, |     Assessment                   |
| and outcomes-based evaluations.   |                                  |
+-----------------------------------+----------------------------------+
| 10\. Health care organizations    | 1.  Data Collection on           |
| should ensure that data on the    |     Race/Ethnicity and Language  |
| individual patient's/consumer's   |                                  |
| race, ethnicity, and spoken and   | 2.  Data Collection on           |
| written language are collected in |     Interpreter Services Used    |
| health records, integrated into   |                                  |
| the organization's management     |                                  |
| information systems, and          |                                  |
| periodically updated.             |                                  |
+-----------------------------------+----------------------------------+
| 11\. Health care organizations    | 1.  Demographics Profile         |
| should maintain a current         |                                  |
| demographic, cultural and         | 2.  Linguistic Profile           |
| epidemiological profile of the    |                                  |
| community as well as a needs      | 3.  Epidemiological Profile      |
| assessment to accurately plan for |                                  |
| and implement services that       |                                  |
| respond to the cultural and       |                                  |
| linguistic characteristics of the |                                  |
| service area.                     |                                  |
+-----------------------------------+----------------------------------+
| 12\. Health care organizations    | 1.  Community Involvement in     |
| should develop participatory,     |     Service Planning             |
| collaborative partnerships with   |                                  |
| communities and utilize a variety | 2.  Service Linkages with Other  |
| of formal and informal mechanisms |     Community Organizations      |
| to facilitate community and       |                                  |
| patient/consumer involvement in   | 3.  Outreach Activities          |
| designing and implementing        |                                  |
| CLAS-related activities.          |                                  |
+-----------------------------------+----------------------------------+
| 13\. Health care organizations    | 1.  Conflict and Grievance       |
| should ensure that conflict and   |     Resolution Processes         |
| grievance resolution processes    |                                  |
| are culturally and linguistically |                                  |
| sensitive and capable of          |                                  |
| identifying, preventing and       |                                  |
| resolving cross-cultural          |                                  |
| conflicts or complaints by        |                                  |
| patients/consumers.               |                                  |
+-----------------------------------+----------------------------------+
| 14\. Health care organizations    | 1.  Publicity on CLAS Related    |
| are encouraged to regularly make  |     Activities                   |
| available to the public           |                                  |
| information about their progress  |                                  |
| and successful innovations in     |                                  |
| implementing the CLAS standards   |                                  |
| and to provide public notice in   |                                  |
| their communities about the       |                                  |
| availability of this information. |                                  |
+-----------------------------------+----------------------------------+

**Appendix C**

Proposed CCATH Candidate Item Set

Project Advisory Committee Meeting

April 4, 2003

*Standard \# 1*

**Health care organizations should ensure that patients/consumers
receive from all staff members effective, understandable and respectful
care that is provided in a manner compatible with their cultural health
beliefs and practices and preferred language.**

##### **Organizational Climate/Culture (Patient Care)** {#organizational-climateculture-patient-care .unnumbered}

**Item 3**

Clinicians openly acknowledge the need for training and development to
deliver culturally appropriate care to patients.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 6**

Patients are treated with dignity and respect.

######### Source: Gardenwartz & Rowe

**Item 8**

Employees are encouraged to find ways to respect the traditions and
beliefs of all the patients

######### Source: Gardenwartz & Rowe

######## Item 9

Employees are open to learning about and caring for ethnic populations
different from their own.

*Source: Gardenwartz & Rowe*

**Item 10**

There is a genuine curiosity about and an appreciation for ethnic and
religious differences.

######### Source: Gardenwartz & Rowe

##### **Service Delivery** {#service-delivery .unnumbered}

**Item 2 a-h**

**c.** Caregivers have been taught specific strategies for taking an
accurate history and physical on culturally and linguistically diverse
patients.

*Source: Salimbene*

**Item 16 (SA)**

Service delivery guidelines incorporate cultural health beliefs and
practices of racial/ethnic groups served.

Source: Garcia/Ma

### 

### Item 17

A range of culturally appropriate service delivery models are planned,
developed and implemented.

*Source: Ministry for Children*

**Item 20 (SA)**

Hospital provides follow up care resource/referral linkages that are
linguistically & culturally appropriate

*Source: Garcia/MA*

### Item 45

Promotional and educational materials are culturally sensitive and
accessible to all client target groups.

*Source: Ministry for Children*

**Item 49**

Changes to the organization's service mix are routinely implemented to
better meet the needs and expectations of racial/ethnic minorities.

*Source: Weech-Maldonado, Dreachslin et al.*

##### **Physical Environment/Food Services** {#physical-environmentfood-services .unnumbered}

**tem 2 a-h**

h\. Caregivers know the dietary and eating habits of patient groups and
take these into account when giving patients a special diet or advice
concerning food to favor or to avoid.

*Source: Salimbene*

**Item 3 a-e**

**d.** In the waiting areas, culturally appropriate refreshments,
reading materials, etc. are available.

*Source: Salimbene*

**Item 5a-b**

a.1) Meals are planned around the eating habits and dietary laws of
major patient groups. a.2) Family members are permitted to bring certain
selected foods to the patient.

b\) Visiting regulations are flexible enough to accommodate the customs
of different groups.

*Source: Salimbene*

**Item 39**

Our agency's environment reflects and welcomes all communities (i.e.
pictures, signs, magazines).

*Source: CCHCP*

##### **Staff Accountability** {#staff-accountability .unnumbered}

**Item 31**

Standards for working with underserved communities are included in staff
job descriptions and performance evaluations.

*Source: CCHCP*

**Item 30**

Performance evaluations have a section on cultural competence.

*Source: Ministry for Children*

**Item 36**

Standards for working with underserved communities are included in
volunteer job descriptions and performance evaluations.

*Source: CCHCP*

**Item 54**

Clinicians are rewarded for delivery of culturally appropriate care to
racially/ethnically

diverse patients.

*Source: Weech-Maldonado, Dreachslin et al.*

###### **Patient Policies**

# **Item 9** 

Policies promote a range of culturally appropriate service delivery
models.

*Source: Ministry for Children*

**Item 19 (SA)**

Policies are in place to provide culturally appropriate patient
education in ER and outpatient care depts.

Source: Garcia/Ma

**Item 24**

Our agency has policies and procedures that address needed services to
all communities.

*Source: CCHCP*

Item 116

Do you have written policies for reviewing and assessing ethnic/cultural
patient needs?

*Source: Andrulis et al.*

Item 118

Do these policies and procedures address all of your ethnic/cultural
patient groups that have substantial numbers of patients?

*Source: Andrulis et al.*

***Standard \# 2***

**Health care organizations should implement strategies to recruit,
retain and promote at all levels of the organization a diverse staff and
leadership that are representative of the demographic characteristics of
the service area.**

**Leadership/Organizational Climate (Workforce)**

**Item 3**

Managers have a track record of hiring and promoting diverse employees.

*Source: Gardenwartz & Rowe*

### 

### Item 4

**At an AGENCY level, this organization\...**Has an institutional
commitment to recruitment and retention of staff reflective of the
population the agency intends to serve.

*Source**:** Louisiana Department of Health*

**Item 6**

Holidays, symbols, celebrations, and rituals of many groups are honored
and respected here.

*Source: Gardenwartz & Rowe*

**Item 14**

Diversity is seen as a business issue that can be a competitive
advantage.

*Source: Gardenwartz & Rowe*

**Item 9**

Top leadership demonstrates a knowledge of different cultural norms in
its behavior.

*Source: Gardenwartz & Rowe*

**Item 14**

A standing committee (task force, action council) monitors the
racial/ethnic diversity climate.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 55**

The CEO speaks with enthusiasm and commitment to the organization's
diversity agenda.

*Source: Weech-Maldonado, Dreachslin et al.*

**Human Resources Policies**

Item 25

Are there human resource policies and procedures in place to address
concerns or complaints concerning unfair treatment in the area of
ethnic/cultural issues?

*Source: Andrulis et al.*

**Item 26**

The organization has an employment equity policy, which eliminates
unfair and discriminatory barriers of accessibility to jobs, and which
has been implemented.

*Source**:** Ministry for Children*

**Workforce Representation**

**Item 8**

The board is selected without paying attention to having community
population represented

######### Source: Gardenwartz & Rowe/ Accountability Questionnaire

**Item 9**

**At an ADMINISTRATIVE level, this organization:** Has a staff
reflecting multicultural diversity at all levels of the organization.

*Source: Louisiana Department of Health*

**Item 29**

The staff reflects the diversity in our area's population.

### *Source: CCHCP*

**Item 8**

Leadership and managerial positions reflect diversity.

*Source: Gardenwartz & Rowe/ Creating a Climate*

**Item 34**

The volunteer pool reflects the diversity in our area's population.

*Source: CCHCP*

**Item 57**

The board of trustees represents the racial/ethnic diversity of the
community.

*Source: Weech-Maldonado, Dreachslin et al.*

**Workforce Recruitment Practices**

**Item 23A-E**

Our agency uses additional recruitment avenues to find applicants such
as

23A. Media serving diverse communities

23B. Informal networks and coalitions

23C. Organizations representing diverse groups

23D. Individuals from diverse communities

23E. Staff and volunteers from diverse communities

*Source: CCHCP*

**Item 26**

Prospective employees are interviewed by a team that is diverse by
race/ethnicity.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 27**

Prompt action is taken to address variances in the rate of job offers by
race/ethnicity.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 50**

Is the ability to speak a second language a consideration in hiring
criteria?

*Source: Anderson*

####### **Workforce Retention/Promotion Practices**

**Item 15**

Benefits have been customized to suit the multiple needs and lifestyle
preferences of employees.

*Source: Gardenwartz & Rowe*

Item 22

Do you have the following activities available?

\(a\) Mentoring

\(c\) Personal counseling/ employee assistance programs

*Source: Andrulis et al.*

**Item 28**

Corrective action is taken promptly when employee turnover ratios vary
by race/ethnicity.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 30**

Racially/ethnically diverse employees with potential for advancement are
systematically identified and supported.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 31**

Formal mentoring programs are emphasized.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 32**

Literacy, GED, English, or foreign language classes are offered at no
charge to all employees.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 33**

Tuition assistance is provided for all employees.

*Source: Weech-Maldonado, Dreachslin et al.*

***Standard \# 3***

**Health care organizations should ensure that staff at all levels and
across all disciplines receive ongoing education and training in
culturally and linguistically appropriate service delivery.**

**Organizational Commitment/Climate (Diversity Training)**

**Item 19**

Racial/ethnic diversity training is provided frequently.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 24**

Resistance to racial/ethnic diversity training is openly discussed.

*Source: Weech-Maldonado, Dreachslin et al.*

# **Item 35**

Funds and staff time are set aside for cultural competency training.

*Source: Ministry for Children*

**Diversity Leadership Training for Executives/Management**

**Item 38**

Executives actively participate in diversity training.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 39**

Managers and other supervisors actively participate in diversity
training.

*Source: Weech-Maldonado, Dreachslin et al.*

**Diversity Training for Staff and Clinicians**

**Item 40**

Physicians actively participate in diversity training.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 41**

Nurses and other caregivers actively participate in diversity training.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 42**

Non-clinical staff actively participates in diversity training.

*Source: Weech-Maldonado, Dreachslin et al.*

**Content /Methods/Effectiveness of Diversity Training**

Item 15

Are staff members educated regarding the special needs and
characteristics of each other;

including the education of one ethnic/cultural group about another
ethnic/cultural group?

\(a\) Cultural beliefs

\(b\) Adherence to treatment regimens (e.g. dietary requirements)

\(c\) Integration with patient-preference for alternative therapies

\(d\) Gender roles

*Source: Andrulis et al.*

**Item 18**

Diversity training is designed in response to systematic assessment of
the racial/ethnic diversity climate and culture.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 20**

External consultants provide diversity training and consultation.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 21**

External consultants train employees who then serve as peer diversity
trainers and advisers.

*Source: Weech-Maldonado, Dreachslin et al.*

#####  {#section-4 .unnumbered}

**Training Related to Language Services**

**Item 60**

Do providers and staff received training on the appropriate use of a
face-to-face interpreter?

*Source: Anderson*

Item 88

Are interpreters trained in cross-cultural medical language?

*Source: Andrulis et al.*

**Item 82**

Is there an ongoing training process in place for staff interpreters?

*Source: Anderson*

**Item 124**

Do providers and staff received training on the appropriate use of a
telephonic interpreter?

*Source: Anderson*

***Standard \# 4***

Health care organizations must offer and provide language assistance
services, including bilingual staff and interpreter services, at no cost
to each patient/consumer with limited English proficiency at all points
of contact, in a timely manner during all hours of operation.

Language Assistance Needs

**Item 22**

Are there demographic size thresholds for cultural and linguistic
communities in your organization's catchment area that determine the
organization's activities for providing linguistic services?

######### Source: Anderson

Item 104

What languages, other than English, are the principal languages of your
patients and staff?

*Source: Andrulis et al.*

Policies (Language Services)

**Item 15**

Is the written policy promoted and distributed to staff?

*Source: Anderson*

Item 67

Does your healthcare organization have written policies that relate to
the provision of interpreter/translator services?

*Source: Andrulis et al.*

Availability of Language Services

**Item 27**

Are interpreters provided at no cost to the patient?

*Source: Anderson*

**Item 31**

Is language access made available during all hours of your institution's
operations?

*Source: Anderson*

Item 70

Does your healthcare organization have interpreter/translator services?

*Source: Andrulis et al.*

Item 87

How or where are translators used for patients:

\(a\) In the emergency room

\(b\) In ambulatory units

\(c\) On inpatient units

\(d\) At discharge

\(e\) On-call for off-shifts

*Source: Andrulis et al.*

Staffing for Language Services

**Item 4**

Is there a department responsible for linguistic services?

*Source: Anderson*

Item 69

Are hospital-based interpreter services required in your state or by any
regulatory agency?

*Source: Andrulis et al.*

**Item 77**

Does your institution hire dedicated staff interpreters? - Full-time? -
Part-time?

*Source: Anderson*

**Item 69**

Are bilingual staff members used as interpreters?

*Source: Anderson*

Item 79

What kind of non-hospital based interpreter/translator services does
your healthcare organization have?

\(a\) AT&T phone translation

\(b\) Friend or family

*Source: Andrulis et al.*

**Item 108**

Does your institution use volunteer interpreters?

*Source: Anderson*

Resources Dedicated to Language Services

Item 80

Does your system allocate support specifically for interpretation
services?

*Source: Andrulis et al.*

Item 81

What is the dollar amount of this support?

*Source: Andrulis et al.*

***Standard \# 5***

**Health care organizations must offer and provide to patients/consumers
in their preferred language both verbal offers and written notices
informing them of their right to receive language assistance services.**

**Verbal and Written Notices on Language Services**

**Item 13**

Do policies for staff and providers explain the regulatory and statutory
obligations for

providing language access to patients with limited English proficiency
(LEP)?

*Source: Anderson*

**Item 19**

Is there a written policy and notice to patients relating to the
availability, at no cost, of

an interpreter?

\- If there is a policy, how is it made available to the patient?

\- Is the statement posted prominently at all points of initial patient
contact?

\- Is it translated into the most common languages served by your
institution?

*Source: Anderson*

***Standard \# 6***

Health care organizations must assure the competence of language
assistance provided to limited English proficient patients/consumers by
interpreters and bilingual staff. Family and friends should not be used
to provide interpretation services (except on request by the
patient/consumer).

Qualifications for Interpreters

**Item 22**

Interpreter Services has minimum performance standards to assure
staff/volunteer competency skills.

*Source: Garcia*

**Item 52**

Are there policies and procedures in place for evaluating individual
language skills of providers and staffs?

*Source: Anderson*

**Item 54**

Is there in place a mechanism to evaluate the basis language skills and
proficiency of

staff believed to be bilingual?

*Source: Anderson*

Item 96

Does your healthcare organization test interpreters in their knowledge
of medical technology?

*Source: Andrulis et al.*

Item 98

Are interpreters accredited, or otherwise evaluated for proficiency?

*Source: Andrulis et al.*

##### **Quality Assessment of Interpreter Services** {#quality-assessment-of-interpreter-services .unnumbered}

**Item 6 (ISC)**

Evaluation tools that assess all three competency skills: translation of
medical terminology, cross-cultural interaction skills, and professional
code of ethics

*Source: Garcia*

**Item 84**

Does the institution perform an annual review of staff interpreters?

*Source: Anderson*

Item 106

Does your healthcare organization measure patients' satisfaction with
your hospital's interpreter/translator services?

*Source: Andrulis et al.*

##### **Policy on Use of Family and Friends as Interpreters** {#policy-on-use-of-family-and-friends-as-interpreters .unnumbered}

**Item 116**

Is there a policy in place prohibiting the use of family or friends as
interpreters?

*Source: Anderson*

**Item 117**

Is this policy made available to patients in their primary language?

*Source: Anderson*

**Item 118**

If a patient insists on using a family or friend as an interpreter, is a
professional

interpreter required to be present anyway?

*Source: Anderson*

***Standard \# 7***

**Health care organizations must make available easily understood
patient-related materials and post signage in the languages of the
commonly encountered groups and/or groups represented in the service
area.**

**Availability of Translated Patient materials**

Item 109

What materials are translated into other languages?

For Patients:

\(a\) Patient education materials

\(b\) Patient menu

\(c\) Patient satisfaction survey

\(d\) Marketing/Advertisements

\(e\) Billing information

\(f\) Directions to sites/services

\(g\) Patient directives (e.g. DNRs)

\(h\) Medication instructions

*Source: Andrulis et al.*

**Item 142**

Are there policy & procedures in place on the use of translation
services?

*Source: Anderson*

**Staffing for Translation Services**

**Item 137**

Is there an assigned department for providing translation services?

*Source: Anderson*

**Item 138**

Is all translation done in-house?

*Source: Anderson*

**Item 139**

Is an external agency used for translation services?

*Source: Anderson*

**Item 149**

Is there qualification in language fluency and translation capacity that
is expected of translators before they are contracted?

*Source: Anderson*

**Item 154**

Is the quality of the translation checked by a second translator?

*Source: Anderson*

**Multilingual Signage**

**Item 6**

All signs are English only, despite a multilingual population.

######### Source: Gardenwartz & Rowe

Item 59 (c )

In addressing the ethnic/cultural needs of patients throughout the
continuum of their care, do you provide [Signs that direct patients to
language/ cultural assistance]{.underline}

*Source: Andrulis et al.*

**Item 147**

Is signage consistently translated through out the organization for
specified

languages?

*Source: Anderson*

***Standard \# 8***

**Health care organizations should develop, implement and promote a
written strategic plan that outlines clear goals, policies, operational
plans and management accountability/oversight mechanisms to provide
culturally and linguistically appropriate services.**

**Organizational Mission**

# 

# **Item 1**

**At an AGENCY level this organization:** Has a written mission or
vision statement supporting multiculturalism throughout the
organization.

*Source: Louisiana Department of Health*

Item 5

Has the board/administration adopted a mission or goals statement that
explicitly incorporates a commitment to cultural diversity?

*Source: Andrulis et al.*

## 

**Strategic Plan**

**Item 2**

Organizational strategic plans incorporate cultural competence goals &
strategies.

######### Source: Garcia

**Item 4**

The strategic plan emphasizes the goal of recruiting and retaining a
workforce representative of the service area's racial/ethnic
demographics.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 5**

The strategic plan emphasizes the goal of ensuring equitable access and
comparable outcomes of care for all racial/ethnic groups in the service
area.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 25**

Is there a written plan for assuring equal access to LEP patients for
threshold ethnic groups?

*Source: Anderson*

**Organizational Structure**

**Item 3**

Is there a specific person or department assigned to promoting diversity
or cultural competence

*Source: Salimbene*

**Item 4**

What is the title of that person or department?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Source: Salimbene*

**Management Accountability**

**Item 8**

The performance review of all employees has diversity-related measures

*Source: Gardenwartz & Rowe*

**Item 56**

Executive and management compensation is based in part on achievement of
racial/ethnic diversity goals.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 37**

Managers are rewarded for involvement in mentoring racially/ethnically
diverse employees.

*Source: Weech-Maldonado, Dreachslin et al.*

Dedicated Resources

Item 32

Is there specific financial support for cultural diversity activities or
programs?

*Source: Andrulis et al.*

***Standard \# 9***

Health care organizations should conduct initial and ongoing
organizational self-assessments of CLAS-related activities and are
encouraged to integrate cultural and linguistic competence-related
measures into their internal audits, performance improvement programs,
patient satisfaction assessments, and outcomes-based evaluations.

Organizational Assessments (General)

**Item 3**

Assesses agency operations for adherence to culturally competent
vision/mission statements

*Source: La Frontera*

**Item 10**

The board evaluates its own performance about its work on cultural
competency.

*Source: CCHCP*

**Item 28**

Our agency evaluates its own performance in its work related to cultural
competency.

*Source: CCHCP*

Item 121

Has consideration of ethnic/cultural minority patient issues been
incorporated into your

healthcare organization's Quality Improvement efforts?

*Source: Andrulis et al.*

Workforce/Staffing Assessment

**Item 7**

The racial/ethnic demographics of the workforce are routinely compared
to the racial/ethnic demographics of the service area.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 11**

Employee satisfaction is routinely evaluated and compared among all
racial/ethnic groups.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 16**

Systematic reviews of recruiting and staffing materials and methods are
conducted to evaluate the responsiveness to racial/ethnic diversity. 

*Source: Weech-Maldonado, Dreachslin et al.*

Service Delivery Assessment

**Item 5**

Examines outcome data by demographic groups and looks for quality
improvement opportunities

*Source: La Frontera*

**Item 15**

Systematic reviews of the physical plant, including aspects such as
artwork on display and design of waiting room areas, are conducted to
evaluate the responsiveness to racial/ethnic diversity.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 19**

Programs are regularly assessed with respect to identifying and
addressing gaps/ barriers or inappropriate services in terms of cultural
needs.

*Source: Ministry for Children*

Patient Satisfaction Assessment

Item 12

Patient satisfaction is routinely evaluated and compared among all
racial/ethnic groups served.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 25**

Patient satisfaction surveys ask questions regarding cultural competence
in service provision.

*Source: Garcia*

**Item 37**

Are patient satisfaction surveys conducted in any language other than
English, including the primary languages served by the organization?

*Source: Anderson*

Item 55

Does your survey ask questions assessing service satisfaction related to
cultural diversity?

*Source: Andrulis et al.*

***Standard \# 10***

**Health care organizations should ensure that data on the individual
patient's/consumer's race, ethnicity, and spoken and written language
are collected in health records, integrated into the organization's
management information systems, and periodically updated.**

**Data Collection on Race/Ethnicity and Language**

**Item 7 (ISC)**

Protocols to gather data on access/ utilization stratified by race,
ethnicity & language.

######### Source: Garcia

**Item 8 (ISC)**

Encounter forms are in place to collect service data by race, ethnicity
& language

######### Source: Garcia

Data Collection on Interpreter Services Used

**Item 43**

Is data collected on the utilization of interpreter services?

*Source: Anderson*

**Item 59**

Is the use of an interpreter documented in the patient's medical record?

*Source: Anderson*

Item 77

Does this office or your healthcare organization maintain a central
registry documenting requests for interpreter/translator services?

*Source: Andrulis et al.*

**Item 123**

Is the use of a telephonic interpreter documented in the patient's
medical record?

*Source: Anderson*

***Standard \# 11***

Health care organizations should maintain a current demographic,
cultural and epidemiological profile of the community as well as a needs
assessment to accurately plan for and implement services that respond to
the cultural and linguistic characteristics of the service area.

##### **Demographics Profile** {#demographics-profile .unnumbered}

**Item 6**

Information about the service area's current and projected racial/ethnic
demographics is routinely gathered.

*Source: Weech-Maldonado, Dreachslin et al.*

#####  {#section-7 .unnumbered}

##### **Linguistic Profile** {#linguistic-profile .unnumbered}

Item 102

Does your healthcare organization identify languages spoken in your
service community?

*Source: Andrulis et al.*

##### **Epidemiological Profile** {#epidemiological-profile .unnumbered}

**Item 9**

Information on the relationship between race/ethnicity and primary
prevention (e.g., smoking, drinking, exercise habits) in the service
area is routinely gathered.

*Source: Weech-Maldonado, Dreachslin et al.*

**Item 10**

The relationship between race/ethnicity and secondary prevention (e.g.,
early detection through health screenings) in the service area is
routinely gathered.

*Source: Weech-Maldonado, Dreachslin et al.*

### Item 14

### At a SERVICE DELIVERY or DEPARTMENTAL level, this organization:

Uses an intentional process (e.g. needs and strength assessment) to
collect information about the local target population from a variety of
sources.

*Source: Louisiana Department of Health*

***Standard \# 12***

Health care organizations should develop participatory, collaborative
partnerships with communities and utilize a variety of formal and
informal mechanisms to facilitate community and patient/consumer
involvement in designing and implementing CLAS-related activities.

Community Involvement in Service Planning

**Item 4**

We regularly work with and/or consult with our community's cultural,
ethnic and religious groups regarding the forms of care and services
which should be made available to their members.

*Source: Salimbene*

### Item 6

**At an AGENCY level, this organization**: Show its commitment to the
communities served by involving community members in the design and
evaluation of services and programs.

*Source: Louisiana Department of Health*

### 

### Item 23 

### At an ADMINISTRATIVE level, this organization: Involves clients and members of the community served in evaluation of the prevention programs.

*Source: Louisiana Department of Health*

Service Linkages with Other Community Organizations

### 

### Item 9

Community of Color and Cultural Identity Institutions

Have you employed the support of:

-   Community Clinics

-   Migrant and Rural Health Services

-   Indian Health Services

-   Transgender Clinics

-   Lesbian, Gay and Bisexual clinics

-   Educational institutions

-   Disability agencies etc. in your research projects?

### *Source: Multicultural AIDS*

### Item 18

### At an ADMINISTRATIVE level, this organization: Has developed service linkages and working relationships with other agencies serving the same client population.

*Source: Louisiana Department of Health*

Outreach Activities

Item 42

Does your healthcare organization engage in the following community
outreach activities:

\(a\) Provide an ombudsman office to assist ethnic/cultural populations?

\(c\) Encourage staff to participate in community meetings?

\(e\) Offer to communities educational programs that address health
beliefs/needs of ethnic/cultural population?

\(f\) Establish or contribute to community support groups for certain
ethnic/cultural populations?

*Source: Andrulis et al.*

Item 46

Media that have a target market of racial/ethnic minorities are
routinely picked for advertising efforts.

*Source: Weech-Maldonado, Dreachslin et al.*

***Standard \# 13***

Health care organizations should ensure that conflict and grievance
resolution processes are culturally and linguistically sensitive and
capable of identifying, preventing and resolving cross-cultural
conflicts or complaints by patients/consumers.

Conflict and Grievance Resolution Processes

### Item 6

Do you document and, if necessary, act on all grievances and
affirmations when People of All Colors, all cultures and all classes,
etc. (consumers of services) call to express their viewpoints?

*Source: Multicultural AIDS*

### Item 24

**At a SERVICE DELIVERY or DEPARTMENTAL level, this organization**:
Documents and acts upon grievances and affirmations, with particular
attention to issues related to cultural differences

*Source: Louisiana Department of Health*

**Item 27**

Hospital makes provisions for accessing culturally & linguistically
appropriate procedures to resolve service grievances.

######### Source: Garcia

###  

***Standard \# 14***

Health care organizations are encouraged to regularly make available to
the public information about their progress and successful innovations
in implementing the CLAS standards and to provide public notice in their
communities about the availability of this information.

Publicity on CLAS Related Activities

### Item 6

Is all information communicated universally through diverse cultural
messengers, mediums and messages to objectively report truth without
creating a spin to manage diversity? (Example: Using outreach workers
from a target group to communicate in their conversational dialect in
recognition of oral tradition within some communities).

*Source: Multicultural AIDS*

### Item 7

Have you disseminated the final findings to all participants and
interested gatekeepers and their communities using multilingual and
multicultural channels of communication?

*Source: Multicultural AIDS*

Item 48

Results of community satisfaction surveys, including differences in
perception among racial/ethnic groups, are openly communicated to the
community.

*Source: Weech-Maldonado, Dreachslin et al.*