Evaluation of the 

National CLAS Standards

Tips and Resources

Malcolm V. Williams, Laurie T. Martin, Lois M. Davis, Linnea Warren May, and Alice Kim

PR-3599-DHHS/OMH
PREFACE
 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 


Community Needs
 

STEP 2: Set Goals and Objectives
 

STEP 3: Develop a Logic Model
 

STEP 4: Identify Evaluation Research 


Questions
 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 


WORKFORCE: Standards 2–4 


COMMUNICATION AND LANGUAGE 


ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Preface 

T he U.S. Department of Health and Human Services (HHS) Office of Minority Health 

(OMH) developed the National Standards for Culturally and Linguistically Appropriate 

Services in Health and Health Care (National CLAS Standards) to provide meaningful and 

practical guidance on delivering culturally and linguistically appropriate services. The National 

CLAS Standards, which are targeted toward health and health care organizations, were revised 

in 2013 to account for the increasing diversity of the U.S. population, the growth in cultural and 

linguistic competency fields, and the changing landscape with respect to new national policies 

and legislation, including the Affordable Care Act. 

The organizations that are adopting and implementing the National CLAS Standards have 

taken concrete steps to address health inequities and meet the needs of the vulnerable 

populations they serve. However, what is less clear is the extent to which these organizations are 

evaluating the impact of their approach to improve inequities in care. 

To help address these questions, OMH commissioned the development of a framework and 

toolkit to guide efforts to evaluate the National CLAS Standards across four settings: ambulatory 

care, behavioral health, hospitals, and public health. 

This work was sponsored by the U.S. Department of Health and Human Services, Office 

of Minority Health under contract No. HHSP233201500038I. The research was conducted in 

RAND Health, a division of the RAND Corporation. A profile of RAND Health, abstracts of its 

publications, and ordering information can be found at www.rand.org/health. 

The RAND Corporation is a research organization that develops solutions to public policy 

challenges to help make communities throughout the world safer and more secure, healthier 

and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. 

© Copyright 2018 RAND Corporation 

2 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Summary
 

Among the many contributors to health inequities, the lack of culturally and linguistically appropriate services in health settings has been recognized as one of the more modifiable factors. 

Improving the availability of such services will not only improve the quality of care provided, but 

may reduce disparities experienced by racial and ethnic minorities and other underserved populations, who struggle because of language, literacy, or other cultural barriers (Saha, Beach, and 

Cooper, 2008). To provide meaningful and practical guidance on delivering culturally and linguistically appropriate services, the U.S. Department of Health and Human Services (HHS) Office 

of Minority Health (OMH) developed the National Standards for Culturally and Linguistically 

Appropriate Services in Health and Health Care (National CLAS Standards). The National CLAS 

Standards, which are targeted toward health and health care organizations (HCOs), were revised 

in 2013 to account for the increasing diversity of the U.S. population, the growth in cultural and 

linguistic competency fields, and the changing landscape with respect to new national policies 

and legislation, including the Affordable Care Act (ACA) (HHS OMH, 2013). 

Successful implementation of the National CLAS Standards requires an organizational 

commitment. Undoubtedly, the National CLAS Standards have helped to increase awareness 

and activities related to the need for culturally and linguistically appropriate services. The 

organizations that are adopting and implementing the National CLAS Standards have taken 

concrete steps to address health inequities and meet the needs of the vulnerable populations 

they serve. However, what is less clear is the extent to which these organizations are evaluating 

the impact of their approach to improve inequities in care. 

3 
SUMMARY
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

To help address these questions, OMH awarded a contract to RAND to develop a framework 

and toolkit to guide efforts in evaluating the implementation of the National CLAS Standards by 

HCOs. The resulting report, Development of a Long-Term Evaluation Framework for the National 

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

presents the details of the development of the framework (Davis et al., forthcoming), while 

this accompanying toolkit distills the elements of the framework and is intended to help guide 

the efforts of HCOs to evaluate the implementation of the National CLAS Standards across four 

settings: ambulatory care, behavioral health, hospitals, and public health. This toolkit is thus 

divided into four sections: 

CHAPTER ONE provides information about the toolkit, who should use it, and what 

it is designed to help you do. 

CHAPTER TWO describes seven steps for implementing and evaluating the National 

CLAS Standards. 

CHAPTER THREE provides additional context and details for evaluating specific 

National CLAS Standards. 

CHAPTER FOUR includes relevant resources and information on potential data 

sources and metrics that may be used in your evaluation. 

4 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

SUMMARY 

The National CLAS Standards 

The National CLAS Standards were intended to advance health equity, improve quality, and help eliminate 

health care disparities by providing a blueprint for individuals and HCOs to implement culturally and 

linguistically appropriate services. The essential goal of the National CLAS Standards is framed in the 

Principal Standard: Provide effective, equitable, understandable, and respectful quality care and services 

that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, 

and other communication needs. 

The remaining 14 Standards span the themes of governance, leadership, and workforce; communication 

and language assistance; and engagement, continuous improvement, and accountability (HHS OMH, 2013). 

GOVERNANCE, LEADERSHIP, AND WORKFORCE 

1.	 Advance and sustain organizational governance and leadership that promotes CLAS and health

equity through policy, practices, and allocated resources.

2.	 Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and

workforce that are responsive to the populations in the service area.

3.	 Educate and train governance, leadership, and workforce in culturally and linguistically appropriate

policies and practices on an ongoing basis.

COMMUNICATION AND LANGUAGE ASSISTANCE 

4.	 Offer language assistance to individuals who have limited English proficiency and/or other

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

5.	 Inform all individuals of the availability of language assistance services clearly and in their preferred

language, verbally and in writing.

6.	 Ensure the competence of individuals providing language assistance, recognizing that the use of

untrained individuals and/or minors as interpreters should be avoided.

7.	 Provide easy-to-understand print and multimedia materials and signage in the languages

commonly used by the populations in the service area.

5 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

SUMMARY 

The National CLAS Standards 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY 

8.	 Establish culturally and linguistically appropriate goals, policies, and management 

accountability, and infuse them throughout the organization’s planning and operations. 

9.	 Conduct ongoing assessments of the organization’s CLAS-related activities and integrate 

CLAS-related measures into measurement and continuous quality improvement activities. 

10. Collect and maintain accurate and reliable demographic data to monitor and evaluate 

the impact of CLAS on health equity and outcomes and to inform service delivery. 

11. Conduct regular assessments of community health assets and needs and use the results 

to plan and implement services that respond to the cultural and linguistic diversity of 

populations in the service area. 

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

services to ensure cultural and linguistic appropriateness. 

13. Create conflict and grievance resolution processes that are culturally and linguistically 

appropriate to identify, prevent, and resolve conflicts or complaints. 

14. Communicate the organization’s progress in implementing and sustaining CLAS to all 

stakeholders, constituents, and the general public. 

More information on the National CLAS Standards and their development can be found on the 

National CLAS Standards website (HHS, undated[b]). 

6 
SUMMARY 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

RAND Research Team 

•	 Project director: Lois M. Davis, Ph.D., senior policy researcher, RAND Corporation 

•	 Co–project director: Allen Fremont, M.D., Ph.D., physician policy researcher and 

sociologist, RAND Corporation 

•	 Marc N. Elliott, Ph.D., senior principal researcher and distinguished chair in statistics, RAND 

Corporation 

•	 Laurie Martin, Sc.D., M.P.H, senior policy researcher, RAND Corporation 

•	 Robert Weech-Maldonado, Ph.D., MBA, professor and L. R. Jordan Endowed Chair of 

Health Administration, University of Alabama at Birmingham 

•	 Malcolm V. Williams, Ph.D., M.P.P, senior policy researcher and associate director, 

Behavioral and Policy Sciences Department, RAND Corporation 

•	 Paul Steinberg, Ph.D., senior communications analyst, RAND Corporation 

•	 Alice Kim, M.P.H, policy analyst, RAND Corporation 

7 
SUMMARY 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Technical Advisory Group 

•	 Margo L. Bailey, Ph.D., M.P.A., HHS and Office of the Assistant Secretary for Planning and 

Evaluation 

•	 Helen Burstin, M.D., M.P.H., FACP, chief scientific officer, National Quality Forum 

•	 Carolyn W. Caldwell, M.S., FACHE, CEO and president, Desert Regional Medical Center 

•	 J. Emilio Carrillo, M.D., M.P.H., vice president, Community Health, NewYork-Presbyterian 

Hospital 

•	 Tawara D. Goode, M.A., assistant professor and director, Georgetown University National 

Center for Cultural Competence and Center for Child and Human Development 

•	 LaMar Hasbrouck, M.D., M.P.H., executive director, National Association of County and City 

Health Officials 

•	 Cara James, Ph.D., director, Office of Minority Health, Centers for Medicare & Medicaid 

Services 

•	 Rodrigo Monterrey, acting director, Office of Health Equity, Massachusetts Department of 

Public Health 

•	 Roslyn Holliday Moore, M.S., senior policy analyst, Office of Behavioral Health Equity, 

Substance Abuse and Mental Health Services Administration 

•	 Gayle Tang, M.S.N., R.N., adjunct professor and health equity consultant 

•	 Alec Thundercloud, M.D., director, Office of Clinical and Preventive Services, Indian Health 

Service 

8 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Chapter 1 

About the Toolkit 

Importance of Evaluating the National CLAS Standards 

The National CLAS Standards have helped to increase awareness and activities related to the 

need for culturally and linguistically appropriate services and, as an organizing principle in 

several instances, they have become a guide for certification and accreditation (e.g., National 

Committee for Quality Assurance [NCQA] toolkit). The National CLAS Standards have clearly led 

some organizations to take concrete steps to address health inequities and meet the needs of 

the vulnerable populations they serve. However, the extent to which the adoption and implementation of the National CLAS Standards occurs across organizations is less clear. Even in the 

systems that may stand out relative to others, the extent to which the National CLAS Standards 

are fully implemented across an organization and for different populations and providers is 

also unclear. 

A closely related concern for health organizations, decisionmakers, policymakers, and 

researchers is that we know relatively little about whether the National CLAS Standards 

will lead to the desired reduction in health inequities when fully implemented. Nor do we 

understand whether some of the National CLAS Standards have more impact than others in 

achieving the goal of reduced inequities. 

9 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 1: ABOUT THE TOOLKIT 

What This Toolkit Is Designed to Do 

This toolkit is designed to support health organizations that are implementing the National 

CLAS Standards and that wish to evaluate their approach to doing so. The toolkit focuses on 

translating the overall evaluation framework into elements that can be adopted by individual 

organizations for their own approach with attention paid to the ways in which the National 

CLAS Standards may improve quality and reduce disparities. The toolkit also aims to strengthen 

the capacity of health care organizations (HCOs) to evaluate the awareness, adoption, 

implementation, and impact of the National CLAS Standards within their organizations. 

Because the toolkit focuses on evaluation, it does not include a lot of information on how 

to identify, design, or implement activities and approaches that your organization may pursue 

to address the National CLAS Standards. However, there are numerous resources available to 

address these issues in more detail. 

•	 The resource library within the U.S. Department of Health and Human Services (HHS)’s 

“Think Cultural Health” website can be filtered by resource type and topic to help you 

identify the most relevant activities and approaches (HHS, undated[c]). 

•	 A Substance Abuse and Mental Health Services Administration (SAMHSA) webinar, 

The National CLAS Standards in Action, explores opportunities for integrating the 

National CLAS Standards into prevention efforts (SAMHSA, 2016b). 

•	 HHS’s Blueprint is an implementation guide to help you advance and sustain culturally 

and linguistically appropriate services within your organization (HHS, undated[b]). 

10 
CHAPTER 1: ABOUT THE TOOLKIT
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Who Should Use This Toolkit? 

This toolkit is designed for individuals responsible for or involved in quality improvement related 

to or evaluation of the National CLAS Standards within health-related organizations. The toolkit 

was designed for use in ambulatory care, behavioral health, hospital, and public health settings, 

although much of the information in this toolkit is broadly applicable to other health providers 

and settings. 

We recognize that HCOs’ ability to self-evaluate and their approach to adopting the National 

CLAS Standards will vary widely. Some organizations will work systematically to implement 

many of the National CLAS Standards, while others will focus on just a few; likewise, some 

organizations will have a great deal of experience and organizational capacity to conduct 

evaluations, while others will have less. This toolkit is interactive to accommodate these 

differences and to allow users to quickly access the information and material that may be most 

helpful to them. 

While organizations of all evaluation capacities will find the information within this toolkit 

useful, we assume that the user has some basic experience with evaluation or continuous 

quality-improvement initiatives. Individuals and organizations with very little evaluation 

experience or capacity may benefit from reading some basic evaluation primers either before or 

in concordance with this toolkit. Examples of evaluation primers are included in Chapter 2. 

11 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 1: ABOUT THE TOOLKIT 

How the Toolkit Is Organized 

As noted, this toolkit is designed to be flexible and interactive so users can quickly jump to the 

information that is most useful. Here we provide a brief description of each remaining section, 

followed by a flow chart to help you figure out where to start. 

•	 Chapter 2 describes seven steps for implementing and evaluating the National CLAS 

Standards. Topics covered include the importance of a needs assessment, setting goals and 

objectives, developing a logic model, and identifying research questions and the data and 

measures that can be used to answer those questions. This section is best for individuals 

newer to evaluation and provides helpful links for more information on many of the steps. 

•	 Chapter 3 builds on the information in Chapter 2, but provides an additional level of 

specificity depending on the National CLAS Standards being implemented. Information in 

this chapter is divided into the three main groups of Standards, including (1) governance, 

leadership, and workforce; (2) communication and language assistance; and (3) 

engagement, continuous improvement, and accountability. For each group, we provide 

additional context, suggest refinements to the logic model, and point to measures that 

may be particularly useful for evaluating each group of Standards. 

•	 Chapter 4 houses the toolkit resources, including detailed information on potential 

measures and item sets, as well as a compilation of other resources listed throughout this 

toolkit. While Chapter 3 provides insight into particular measures relevant for each group 

of standards, this section sorts measures by health setting, as some measures and metrics 

are already being collected or may be most relevant for one setting. 

12 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 1: ABOUT THE TOOLKIT
 

FIGURE 1. EVALUATION TOOLKIT FLOW CHART: FIGURING OUT WHERE TO START
 

How much experience do you have 

with evaluation? 

A great deal 

Some to very little 

How familiar are you with the 

National CLAS Standards? 

Very familiar 

Do you know which National CLAS 

Standards you are addressing? 

Yes 

Are you looking for additional 

information on how to evaluate those 

standards? 

Yes 

The standards are new 

to me 

I am not sure yet 

No, I am just looking 

for a list of potential 

measures and other 

resources 

Chapter 2. Getting Started 

Chapter 1. About the Toolkit 

Chapter 2. Getting Started 

Chapter 4. Evaluation 

Resources 

Chapter 3. Tips for evaluating the 

National CLAS Standards 

13 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Chapter 2
 

Getting Started
 

Most health organizations have limited resources, meaning that the dollars, 

resources, and personnel time that organizations use must be allocated to 

activities and efforts that work. Effective evaluations can help organizations 

learn about what works to make better decisions about how they spend their 

resources. 

Evaluating the implementation of the National CLAS Standards and their 

impact can be complicated, but the process can be made easier by breaking 

it down into steps. Through these steps, your organization will define how to 

measure progress toward its goals. You will also define how to measure the 

impact these changes have on your organization, as well as on the individuals 

you serve. Evaluating the impact of the National CLAS Standards is best 

thought of as an iterative process that may supplement existing ongoing 

quality improvement efforts. This allows your organization to make necessary 

changes along the way. 

RESOURCES NEEDED FOR 

EVALUATION 

To complete an 

evaluation, HCOs will 

need the following: 

•	 information about 


the National CLAS 


Standards they are 


implementing
 

•	 capacity to collect 

baseline information 

about the target 

population 

•	 ability to adapt the 

evaluation framework 

to their local context 

•	 understanding of 


Continuous Quality 


Improvement (CQI) 


principles 


•	 a long-term 

commitment to collect 

and analyze data. 

14 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED
 

STEP 1: Assess Organizational and Community Needs 

The first step is to assess the needs of the organization and community. An organizational needs assessment can help you identify which 

of the National CLAS Standards you are already meeting and where 

there is room for improvement. This step should also include a community needs assessment. 

The purpose of a needs assessment is to identify the problems your 

clients, patients, or their family members have accessing high-quality 

services. This allows you to prioritize approaches to meeting these 

needs. The information you draw to define these needs will come 

from existing data you collect through surveys and other surveillance 

methods, as well as data collected by outside organizations. You will 

also want to directly engage patients, community members, and their 

families through public forums or more directly through focus groups 

and interviews. Consulting experts may also be important (Wiseman 

et al., 2007). 

SEVEN STEPS FOR 

IMPLEMENTING AND 

EVALUATING THE 

NATIONAL CLAS 

STANDARDS 

1.	 Assess organizational 

and community needs. 

2.	 Set goals and 

objectives. 

3.	 Develop a logic 

model. 

4.	 Identify evaluation 

research questions. 

5.	 Choose measures. 

6.	 Design evaluation and 

collect data. 

7.	 Share findings and 

make changes as part 

of CQI. 

15 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 1: Assess Organizational and Community Needs 

In this section, we provide links to several resources to help you plan and implement a needs 

assessment. The first link (self-assessment tool) is a comprehensive review of how a needs assessment can be conducted, specifically for planning and implementing the National CLAS Standards. It provides an in-depth review of a methodology for developing a CLAS-specific self-assessment tool. Although needs assessments can be complicated (and expensive), they do not 

have to be (Wiseman et al., 2007). The second link (toolkit) we provide describes a less-intensive 

approach that identifies the key steps to a community needs assessment in community-based 

chronic disease prevention, including 

• identifying a community team 

• describing the scope of the assessment 

• listing the questions to ask 

• selecting sites 

• determining data collection methods or sources 

• identifying key informants 

• reviewing and rating data collected from a community needs assessment 

• summarizing data 

• developing and prioritizing strategies for improvement 

• creating a community action plan. 

16 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 1: Assess Organizational and Community Needs 

More information on needs assessments is provided here: 

•	 Self-assessment tool from HHS designed to help local public health agencies assess 

their culturally and linguistically appropriate services (HHS OMH, 2003). It is also 

relevant for other health providers. 

•	 Toolkit from the Centers for Disease Control and Prevention (CDC) focusing on 

conducting community needs assessments for chronic disease prevention (CDC, 

2013). 

•	 Article by Olavarria et al. (2009) describing how to conduct a self-assessment 

of organizational cultural competence in community health and social service 

organizations. 

•	 Resources from Community Tool Box and its related toolkit containing 

information about assessing the needs of your community (Community Tool Box, 

undated[a], undated[b]). 

17 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 2: Set Goals and Objectives 

After you have completed your needs assessment, you can use the findings to set your 

goals and objectives. What do you want to accomplish? How can implementation of the 

National CLAS Standards help you reach this goal? It is important to identify goals for 

your approach, including identifying the people you will target through implementation 

of the National CLAS Standards, the desired outcomes, and the objectives. Doing so 

helps define what will be considered a success. Goals should be broad and define what 

you intend to improve in the long term. Objectives are also important and should be 

written in a way that defines how the goals can be measured by describing “what will 

change, for who, by how much, and by when?” (Chinman, Imm, and Wandersman, 

2004). 

As you develop your goals and objectives, it may be helpful to draw on this 

framework that conceptualizes the National CLAS Standards as an innovation to be 

adopted within health care settings (Figure 2). 

18 
CHAPTER 2: GETTING STARTED
 

STEP 2: Set Goals and Objectives 

FIGURE 2. CONCEPTUAL FRAMEWORK FOR DIFFUSION OF NATIONAL CLAS STANDARDS
 

RAND RR2157-2.1

National CLAS Standards Environmental and Policy Context 

Framework and guide to Activities depicted in this model occur within a broader environmental and policy context. This includes, for example, the 

health care providers and regulatory environment, mandates, and standards of practice. The dashed lines around the organization indicate that this 

policymakers for ensuring context is likely to influence an organization’s readiness for change; whether, when, and how National CLAS Standards are 

quality of care and needs of adopted; and the ease at which changes within the organization can be made to meet National CLAS Standards. 

diverse populations are met. 

The overarching goal, or the 

Principal Standard, is “to 

provide effective, equitable, 

understandable, respectful, 

and quality care and services” 

(Standard 1). 

The overall standard has three 

themes: 

• 	Governance, Leadership, and 

Workforce (Standards 2–4) 

• 	Communication and 

Language Assistance 

(Standards 5–8) 

• 	Engagement, Continuous 

Improvement, and 

Accountability 

(Standards 9–15) 

Engagement and Partnerships 

Linkages between the health 

organization, the community, 

and other stakeholders are 

present at all stages of 

National CLAS Standards 

adoption. They provide 

relevant inputs and information to help assess need and 

guide the process; participate 

in the design, adoption, and 

implementation of activities; 

support communication about 

changes; and are impacted by 

outputs and outcomes. 

Linkages evolve over time to 

include new partners and 

tasks. 

National 

CLAS Standards 

Readiness for National CLAS 

Standards 

Development of 

implementation strategies and 

communication 

Adoption and implementation 

Antecedents and inputs 

Outputs and outcomes 

Engagement and 

partnerships 

LINKAGE 

LINKAGE 

ENVIRONMENTAL AND POLICY CONTEXT 

Health Organization 

Quality improvement 

HHS OMH 

Community 

Other stakeholders 

Antecedents and Inputs 

Includes the organization’s 

structure, internal and external 

resources, and their capacity and 

receptivity for change 

Readiness 

Captures the extent to which an 

organization recognizes the need 

for change and has made National 

CLAS Standards an organizational 

priority 

Development of Implementation 

Strategies and Communication 

Includes development of changes 

an organization intends to 

implement to address gaps in 

culturally and linguistically 

appropriate care and services as 

well as strategies to implement 

those changes. Proposed changes 

are communicated internally and 

externally to the community and 

stakeholders. 

Adoption and Implementation 

Activities identified to address 

gaps are implemented (e.g., 

training and workforce; 

collection, monitoring, and use of 

data; changes in procedures, 

protocols, or physical space; 

changes to leadership and 

governance) 

Outputs and Outcomes 

Captures immediate changes as a 

result of implemented activities 

(outputs) as well as short-, 

medium-, and long-term 

outcomes for both consumers and 

the organization 

19 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 2: Set Goals and Objectives 

Consider these questions as you identify your goals and objectives: 

•	 What were the highest priorities identified in the needs assessment? Which National CLAS 

Standard(s) can help you to address those needs? 

•	 What broader contexts (e.g., regulatory environment, mandates, standards of practice) 

might influence what your goals and objectives are and which National CLAS Standards 

might you adopt first? Are there opportunities to align your goals and objectives with 

these broader contexts? 

•	 Which stakeholders and community members or groups should you engage to help set 

your goals and objectives? 

•	 How should you communicate your goals and objectives both internally and externally to 

community stakeholders? 

20 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 3: Develop a Logic Model 

The third step for implementing and evaluating the National CLAS Standards is to develop a 

logic model, sometimes called a theory of change. Logic models help you to map out why you 

think the activities and efforts you want to implement will result in the goals and objectives you 

have identified. It can be thought of as a series of “if. . . then” statements. When done well, the 

logic model provides alignment between activities and outcomes, making it easier to develop or 

choose metrics and evaluation questions. In the example below, the activities related to staffing 

changes are aligned with data at the organization level on the composition of the staff as well 

as their capacity to provide care to a diverse patient population. 

To help you with logic model development, we offer a template for a logic model related 

to implementation of the National CLAS Standards (see Figure 3). Here, the National CLAS 

Standards are viewed as a perspective or lens through which context and antecedents are 

interpreted and help shape the specific Standards the organization chooses to implement to 

address gaps in culturally and linguistically appropriate care within their setting. More-detailed 

templates for the ambulatory care, behavioral health, hospital, and public health settings are 

also available as part of this toolkit. Specific guidance on how to shape your logic model for 

each of the Standards can be found in Chapter 3. 

For more information on developing a logic model, see: 

•	 Guide from CDC on developing and using a logic model (CDC, 2017a)

•	 Resource list from SAMHSA on developing a logic model to guide program evaluation

(SAMHSA, undated).

21 
RAND RR2157-3.1

CHAPTER 2: GETTING STARTED
 

STEP 3: Develop a Logic Model 

FIGURE 3. LOGIC MODEL TEMPLATE 

Proposed Changes and Strategies to Context, Antecedents, and Inputs Implement Those Changes 

Community/stakeholders 

• Hospitals

• Other ambulatory care 

• Public health 

• Insurers

• Community health workers/promotores de 

salud 

• Community organizations 

o Social service 

Environmental/policy context 

• Affordable Care Act (ACA) 

• Accreditation (e.g., Joint Commission 

standards) 

• Value-based care and payment models 

• Triple Aim: cost, quality, experience 

• Title VI of 1964 Civil Rights Act 

• Consumer informatics 

Ambulatory care context/resources 

• Size and structure 

• Part of network 

• Organizational policies, priorities 

• Resources

o Financial

o Staff time, skills, and capacities 

o Interpretation and translation services 

o Physical space, equipment 

• Needs assessment 

o Gaps in activities, structures, and policies 

o Gaps in implementation factors 

Community/catchment area 

• Ethnicity, culture, and language 

• Urban or rural 

• Engagement with ambulatory care 

o Boards, planning committees, and input 

• Unmet needs 

National CLAS Standards 

Changes to 

organizational 

policies 

Changes to 

processes 

and 

practices 

Changes to 

structure, 

staffing, and 

resources 

Outputs 

Diverse viewpoints from within and outside of 

the organization are incorporated in 

organizational planning. 

National CLAS Standards are built into 

organization’s mission, goals, and policies, and 

are central to the organization’s functions. 

Increased knowledge and skills for all staff 

related to delivering culturally and linguistically 

appropriate care at all levels of the organization 

Organization has ethnically diverse providers and 

staff at all levels, including boards and senior 

administration 

Standards of practice implemented around clear 

communication, access to language services, and 

notification of rights 

Written information (e.g., instructions, consent 

forms) is developed and provided in multiple 

languages. 

Improvement in physical layout, signage, ease of 

access, and navigation 

Dedicated resources and accountability to 

support/sustain initiatives and efforts related to 

the National CLAS Standards, including language 

services 

Improved collection of, access to, geographic 

mapping of, and dissemination of accurate 

population data, particularly for ethnic and 

minority populations 

An understanding of the assets and needs of the 

organization and service area is achieved. 

Transparency within and outside organization is 

attained with respect to implementation of the 

National CLAS Standards. 

Continuous improvement 

Outcomes and Impacts 

Longer Term 

Organization 

Provision of quality care and services that are 

responsive to preferred languages, health 

literacy, and other communication needs 

Data on race, ethnicity, sex, disability status, and 

language are used to monitor and improve 

service delivery within ambulatory care setting. 

Individual/Client 

Improved two-way communication and 

feedback mechanisms between individuals and 

providers 

Racial/ethnic/linguistic concordance between 

providers and patients 

Individuals are better able to access and 

navigate ambulatory care setting to receive 

primary, preventive, and acute care services. 

Individuals are better able to understand their 

treatment options and make informed care 

decisions. 

Individuals understand and can navigate referral 

process to see specialists. 

Individuals have greater adherence to 

medication and treatment protocols and 

follow-up visits. 

Shorter Term 

Organization 

Provision of quality care and services that are 

responsive to diverse cultural health beliefs 

Continued improvement in provision of 

high-quality services related to National CLAS 

Standards 

Individual/Client 

Better patient outcomes, improved safety, 

higher-quality care, higher patient satisfaction 

Increased equity in access to high-quality 

services and a reduction in health disparities 

Increased trust and engagement between 

communities and ambulatory care setting 

Organizational culture shifts to provide ongoing 

and visible support for National CLAS Standards 

Individuals have access to high-quality language 

services. 

Individuals are empowered to become active 

participants in their health. 

Increased use of appropriate care services with 

regular follow-up and continuity of care 

Improved satisfaction among individuals seeking 

ambulatory care services 

Reduced disparities 

Improved health and well-being 

Increased trust in and engagement with the 

provider and ambulatory care setting more 

broadly 

22 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 4: Identify Evaluation Research Questions 

The following evaluation questions, developed in partnership with HHS OMH, were designed to 

capture important short- (1–2 years) and longer-term (3 or more years) outputs and outcomes 

for health organizations and the individuals they serve. In the short term, it is more likely that 

an organization can develop a set of activities that improves the outputs. This might involve 

providing services that are responsive to preferred language and other communication needs. 

But it will take much longer to achieve and measure changes in outcomes with populations that 

have these communication needs. While not all questions may be relevant to your efforts, and 

you may wish to add supplemental questions specific to your efforts, HHS encourages the use 

of a consistent set of evaluation research questions across a range of providers and settings for 

several reasons: 

1.	 Using similar questions ensures that organizations are capturing short- and longer-term 

outcomes that are of the highest importance for improving access to culturally and linguistically appropriate health care services. 

2.	 It allows for more-direct comparisons of findings across settings and systems to identify 

particularly effective models or approaches that may be shared more broadly. 

3.	 It allows for a collective look at the impact of implementing the National CLAS Standards 

on organizations and individuals accessing care and services. 

Chapter 3 provides additional resources and information to help shape your evaluation 


questions. Next, we provide examples of important short- and long-term outcomes.
 

23 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 4: Identify Evaluation Research Questions 

SHORT-TERM OUTCOMES (1–2 YEARS) 

For organizations 

•	 To what extent has the implementation of the National CLAS Standards led or contributed 

to 

– the use of data on race, ethnicity, sex, disability status, and language to monitor and 

improve health service delivery? 

– improved two-way communication between providers and clients? 

– increased knowledge of culturally and linguistically appropriate care and buy-in from 

staff? 

– better and earlier detection of health care concerns through appropriate screening? 

For clients/individuals 

•	 To what extent has the implementation of the National CLAS Standards resulted in 

– improved access to high-quality language services for ethnic and minority populations? 

– consumers being better able to access and navigate health care services? If so, in what 

ways? 

– increased consumer understanding of health care treatment options and to moreinformed care decisions? 

– greater adherence to medication, treatment protocols, and follow-up visits? 

24 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 4: Identify Evaluation Research Questions 

LONGER-TERM OUTCOMES (3 OR MORE YEARS) 

For organizations 

•	 To what extent has the implementation of the National CLAS Standards led to a cultural 

shift in the organization toward greater awareness of and workforce buy-in of culturally 

and linguistically appropriate care and services? 

•	 To what extent has the implementation of the National CLAS Standards led or contributed 

to 

– improvements in the provision of high-quality health care services for diverse 

populations? 

– improved health outcomes for ethnic and minority populations? 

– increased trust and engagement between patients and providers? 

– increased trust and engagement between the community and HCOs? 

– increased equity in access to health services? 

– reduction in disparities in health outcomes? 

– increased capacity of the HCO or health system to address the needs of a diverse 

population? 

25 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 4: Identify Evaluation Research Questions 

LONGER-TERM OUTCOMES (3 OR MORE YEARS) 

For clients/individuals 

• To what extent has implementation of the National CLAS Standards led to 

– individuals feeling empowered to become active participants in their health care? 

– improved satisfaction among individuals seeking health care? 

– increased trust and engagement between individuals seeking care and treatment 

providers? 

• To what extent has implementation of the National CLAS Standards contributed to 

– increased use of appropriate health care services with regular follow-up and continuity 

of care? 

– increased equity in outcomes of health services? 

– improved health, family, and social functioning, and overall well-being? 

26 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 5: Choose Measures 

You can use the logic model you created in Step 3 and the evaluation questions in Step 4 to 

help you think about what types of data you will need. You do not need to measure everything. 

Think about what measures might capture the most-important processes or outcomes related to 

the specific National CLAS Standards you are implementing. Given that data collection can be a 

resource-intensive process, you should also think about what types of measures you already use 

and what types of data you already collect that may be helpful for your evaluation. 

More information on metrics and methods for assessing each Standard can be found in 

Chapter 3, and the appendixes provide tables of measures that may be helpful for your 

evaluation. For each measure, you can see its description, area of focus (e.g., cultural 

competency, language services), the source and item number, notes, and references. In some 

cases, the measure listed in the table is an item set or a grouping of measures. Clicking on the 

name of the item set will give you the topic area and specific wording of each of the items in 

that set. Measures are grouped by setting for quick reference to measures that may be most 

relevant to you. 

27 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 6: Design Evaluation and Collect Data 

Once you have identified your research questions and the measures that will help you answer 

those questions, the next step is to formally design your evaluation and to think in particular 

about your plan for collecting data. 

•	 Who are you involving in your evaluation (e.g., consumers, stakeholders, staff)? How will 

you recruit them? How many individuals from each group are you including? 

•	 Will you have a comparison group? 

•	 When are you collecting data? Are you assessing changes over time? At what time points? 

•	 How are you collecting data? What are your mode(s) of data collection (e.g., survey, 

interview, focus group)? 

The following resources provide additional information on evaluation design and 

implementation, which can help you to determine the most-appropriate data-collection 

approaches for your evaluation: 

•	 CDC’s Introduction to Program Evaluation for Public Health Programs: A Self-Study Guide 

provides useful introductory information (CDC, 2012). 

•	 The Substance Abuse and Mental Health Services Administration (SAMHSA) has a 

list of evaluation tools and resources that can help with planning and management, 

implementation, and analysis of data and evaluations (SAMHSA, undated). 

•	 RAND’s Getting to Outcomes toolkits help communities and organizations implement and 

evaluate their prevention programs (RAND Corporation, undated). 

28 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 2: GETTING STARTED 

STEP 7: Share Findings and Make Changes as Part of CQI 

The last step in the process is to analyze the data you collected and to use those findings to inform your next steps. Given the importance of the community, stakeholders, and partners to the 

implementation of the National CLAS Standards and the ongoing assessment of providing culturally and linguistically appropriate services, sharing the findings with the community is essential. Findings should also be shared within your organization, where successes can be celebrated 

and continued gaps can be reassessed. 

As noted earlier, implementation of the National CLAS Standards is not a one-time effort, 

but rather an important component of your organization’s CQI efforts. While many health 

organizations have quality-improvement processes in place, additional resources on the 

importance of ongoing quality improvement and how to develop and implement a quality 

assurance plan can be found here: 

•	 The Health Resources and Services Administration’s Quality Improvement 

and Developing and Implementing a QI Plan (HHS, Health Resources and Services 

Administration, 2011a; HHS, Health Resources and Services Administration, 2011b) 

•	 New York State Office of Mental Health’s Quality Improvement Plan Template (2005) 

•	 CQI in the Electronic Health Record Implementation Lifecycle (National Learning 

Consortium, 2013). 

29 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Chapter 3 

Tips for Evaluating the 

National CLAS Standards 

Chapter 2 provided an overview of seven steps for implementing and evaluating the National 

CLAS Standards. However, for an evaluation to be effective, it must be specific to the planned 

activities, processes, and outcomes relevant to the National CLAS Standards that are being implemented. Therefore, this chapter provides additional context and considerations that may be 

helpful for evaluating specific sets of Standards. We provide additional information on each set 

of Standards, note what the expected outcomes of successful implementation should be, discuss 

how your logic model could be shaped to reflect the specific Standards you are implementing, 

and provide potential measures that are particularly relevant for each set of Standards. 

This section is divided into four parts: 

• Principal Standard (Standard 1) 

• Governance, Leadership, and Workforce (Standards 2–4) 

• Communication and Language Assistance (Standards 5–8) 

• Engagement, Continuous Improvement, and Accountability (Standards 9–15). 

30 
CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

PRINCIPAL STANDARD: Standard 1 

Provide effective, equitable, understandable, and respectful quality care and services 

that are responsive to diverse cultural health beliefs and practices, preferred 

languages, health literacy, and other communication needs. 

WHY IS THIS STANDARD IMPORTANT? 

STANDARD 1 is the Principal Standard of the National CLAS Standards and encompasses many 

practices and policies related to providing equitable, effective, and quality care to culturally and 

linguistically diverse populations. Thus, by successfully implementing activities to address the 

other standards (summarized in the following sections, navigable via the sidebar), your organization will achieve Standard 1. Standard 1 names several important components: (1) effective 

and equitable care and services, including health promotion, disease prevention, diagnosis, 

treatment, mental and behavioral health, emergency care, and more, focuses on reducing the 

burden of illness and injury based on race, education, age, religion, language, gender, and 

income to improve the health of all people; (2) respectful services fosters an environment where 

all individuals feel comfortable discussing their needs with staff members; (3) the recognition of 

cultural beliefs and practices and acknowledgment of patients’ preferred language ensures that 

staff consider culturally informed health beliefs and use appropriate communication techniques. 

31 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

PRINCIPAL STANDARD: Standard 1 

By addressing this Standard, you will 

•	 ensure that consumers with limited English proficiency or other communication needs 

receive equitable access to services 

•	 help consumers understand their health care and service options and allow them to 

participate in health care decisionmaking 

•	 increase satisfaction with care 

•	 improve adherence to recommendations and treatments 

•	 improve consumer safety and reduce miscommunications that contribute to medical errors 

•	 aid in compliance with requirements, such as Title VI of the Civil Rights Act of 1964, the 

Americans with Disabilities Act of 1990, and other relevant policies. 

32 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

PRINCIPAL STANDARD: Standard 1 

HOW COULD I SHAPE MY LOGIC MODEL TO REFLECT THIS 

STANDARD? 

In Chapter 2, the idea of a logic model was introduced. Logic models can help you think through 

your evaluation in greater detail to ensure that you measure what is important. Standard 1 is the 

Principal Standard because the adoption of the remaining Standards would achieve Standard 1. 

Standards 2–15 represent the activities, outputs, and outcomes (elements of the logic model) 

intended to be the building blocks of culturally and linguistically appropriate services that will 

help you achieve the Principal Standard. For this reason, ways of shaping your logic model 

specific to Standard 1 are not listed here. If activities that support each of Standards 2–15 are 

implemented and maintained, organizations will be better positioned to achieve the desired 

goal. 

In Table 1, we provide some example metrics you can use to assess your progress toward implementing practices that align with Standard 1, as well as the impact of those processes on your 

organization and those you serve. The metrics highlighted for Standard 1 focus on delivering 

equitable and high-quality services and will supplement those you may collect to assess the other 

National CLAS Standards. This is not a comprehensive list, but it will help you get started and 

may complement metrics you already collect. Additional information on the measures, including 

links to survey documents, can be found in Chapter 4. 

33 
CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

TABLE 1. METRICS AND WAYS OF ASSESSING STANDARD 1 

EXAMPLE METRIC	 DESCRIPTION 

Communication 

Climate 

Assessment 

Toolkit (C-CAT), all 

domains 

The C-CAT provides assessments of consumers, staff, and organizational leadership to 

comprehensively measure the implementation and outcomes of providing language 

services. C-CAT has been validated in diverse health care settings nationwide. C-CAT 

scores are calculated on nine domains. 

All C-CAT domains are relevant for this Standard. Specific items related to equitable, 

high-quality care assess 

•	 whether staff have communicated with one another effectively to ensure highquality care 

•	 whether clinical quality measures are compared across patient demographic 

groups 

•	 sharing of communication quality assessments with staff 

•	 patient perceptions of quality of care 

•	 patient perceptions of whether the organization serves the community well. 

Cultural 

Competency 

Implementation 

Measure: 

Commitment to 

Serving a Diverse 

Population 

and Quality 

Improvement 

subdomains 

The Cultural Competency Implementation Measure is an organizational survey designed to assist health care organizations in identifying the degree to which they are 

providing culturally competent care and addressing the needs of diverse populations. 

The Cultural Competency Implementation Measure was designed for use in diverse 

health care settings. Scores are calculated for 12 subdomains. 

The Commitment to Serving a Diverse Population and Quality Improvement subdomains are most relevant for this Standard and include items assessing 

•	 whether a vision statement, goals, and mission have been developed and/or 

revised to ensure they reflect a commitment to providing high-quality, culturally 

competent care for diverse populations 

•	 development of an action plan that includes explicit expectations and 


measurable objectives relating to culturally competent care
 

•	 whether, based on national benchmarks, organizational targets and benchmarks 

were set for performance measures 

•	 whether information on patients’ race, ethnicity, and primary written and 

spoken language were used to design and/or inform quality improvement 

strategies and projects focused on providing more culturally competent care and 

eliminating health care disparities in access, outcomes, or patient experiences 

with care. 

34 
CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

Standard 2. Advance and sustain organizational governance and leadership that 

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

Standard 3. Recruit, promote, and support a culturally and linguistically diverse 

governance, leadership, and workforce that are responsive to the populations in the 

service area. 

Standard 4. Educate and train governance, leadership, and workforce in culturally 

and linguistically appropriate policies and practices on an ongoing basis. 

WHY ARE THESE STANDARDS IMPORTANT? 

The implementation of culturally and linguistically appropriate services is a systemic responsibility, requiring the investment, support, and training of all individuals within an organization. 

Standard 2 emphasizes the importance of advancing and sustaining governance and leadership 

that promotes the National CLAS Standards and health equity through policies, programs, and 

resource allocation. The National CLAS Standards are applicable to all of the work your organization does, and traditionally, cultural competency efforts have proceeded from the bottom up. 

However, the culture of an organization is really established through its leadership and governance through the policies, expectations, and actions performed. Your organization should not 

only be culturally and linguistically diverse in its leadership, but should also put forth policies 

and procedures that make a commitment to cultural competency and equity visible to your staff 

and those you serve. 

35 
CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

Standard 3 illustrates that it is important for organizations to ensure that their leadership and 

workforce are culturally and linguistically diverse in order to be responsive to the populations 

they serve. Evidence shows that organizations with a more racially and ethnically diverse 

workforce are better able to provide high-quality care, improved communication, and greater 

patient satisfaction, and this is becoming increasingly important as the United States becomes 

more diverse. Unfortunately, this diversity is not represented in many health-related professions. 

Therefore, it is essential that organizations develop focused strategies to recruit, promote, 

and support a culturally and linguistically diverse workforce, from front desk staff to senior 

leadership to external contractors and partners. However, diversity alone is not sufficient to 

achieve cultural competency: All members of your organization should also be trained in cultural 

and linguistic competency skills. 

Standard 4 summarizes the importance of providing ongoing education and training for 

professionals. Cultural and linguistic competency concepts—including effective communication 

and patient-, family-, and community-based practices—should be incorporated not only into 

all formal educational curricula but also into new and existing staff training and curricula. 

Ongoing education and staff training ensures that your governance, leadership, and workforce 

are equipped with adequate knowledge, tools, and skills to appropriately manage cross-cultural 

encounters with the consumers you serve. While principles of cultural competency should 

carry through all education, training, policies, and procedures, specific opportunities exist for 

training your staff on such subjects as health disparities or the effect of current and historical 

36 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

events on medical mistrust experienced by the populations you serve. Consistently reinforcing 

your commitment to cultural and linguistic competency creates buy-in within your workforce. 

Culturally competent practices have also been shown to have positive impacts for consumers, 

including services efficiency, satisfaction, and outcomes. 

Your organization can use a variety of approaches for addressing Standards 2–4, depending 

on the type of services you offer. As is discussed for all of the National CLAS Standards, it is 

important to monitor the quality and use of services. 

By addressing these Standards, you will: 

Standard 2 

•	 ensure the provision of appropriate resources and accountability needed to support and 

sustain initiatives 

•	 model an appreciation and respect for diversity, inclusiveness, and all beliefs and practices 

•	 support a model of transparency and communication between your organization and the 

populations you serve. 

Standard 3 

•	 create an environment in which culturally diverse individuals feel welcomed and valued 

•	 promote trust and engagement with the communities and populations you serve 

•	 infuse multicultural perspectives into planning, design, and implementation of CLAS 

•	 ensure diverse viewpoints are represented in governance decisions 

•	 increase knowledge and experience related to culture and language among staff. 

37 
CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

Standard 4 

•	 prepare and support a workforce that demonstrates the attitudes, knowledge, and skills 

necessary to work effectively with diverse populations 

•	 increase the capacity of staff to provide services that are culturally and linguistically 

appropriate 

•	 assess the progress of staff in developing cultural, linguistic, and health literacy 

competency 

•	 foster an individual’s right to respect and nondiscrimination by developing and 

implementing education and training programs that address the impact of culture on 

health and health care. 

38 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

HOW COULD I SHAPE MY LOGIC MODEL TO REFLECT THESE 

STANDARDS? 

In Chapter 2, the idea of a logic model was introduced. Logic models can help you think through 

your evaluation in greater detail to ensure that you measure what is important. In this section, 

we provide some ideas for how you might think about building out a logic model to evaluate 

your implementation of Standards 2–4. Every organization is different, but we provide some 

examples of things to consider as you tailor your logic model to implement and assess activities 

that aim to meet standards related to governance, leadership, and workforce. 

Consider, for example, the context, antecedents, and inputs that highlight the cultural and 

linguistic factors that should inform changes to policies and practices: 

•	 cultural and linguistic characteristics of the population(s) you serve 

•	 current workforce demographics and promotion demographics 

•	 current training procedures, opportunities for new training, and availability of cultural 

competency training resources in your area (including live and web-based resources) for 

all senior leadership, management, staff, and volunteers. 

39 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

Implementation of the National CLAS Standards often requires changes 

to or the development of new policies, procedures, and staffing. Your 

logic model should include the activities that you have adopted and 

implemented. Some examples related to Standards 2–4 are listed below. We 

have organized the examples to highlight the outputs named in our sample 

logic model: changes to organizational policies; changes to structure, 

staffing, and resources; and changes to processes and practices. 

Changes to organizational policies 

• A written policy that reinforces the organization’s commitment to 

– consumers’ rights to respect and nondiscrimination 

– a diverse workforce at all levels of leadership 

– mentorship and promotion opportunities for a diverse staff 

– ongoing training for governance, leadership, and staff in 

culturally and linguistically appropriate practices. 

IMPLEMENTATION 

IN ACTION: 

Organizational Changes 

at Woodhull Medical and 

Mental Health Center 

(Standard 4) 

At Woodhull Medical and 

Mental Health Center, 

in Brooklyn, N.Y., the 

leadership sought to 

make sweeping changes 

to its practices related 

to cultural competency. 

Framed as a patient safety 

and customer service issue, 

leadership changed the 

organization’s mission to 

affirm their commitment 

to cultural competency. 

Staff now collect data on 

language preferences and 

interpretation needs and 

use staff interpreters, with 

a telephone language line 

vendor as backup. Cultural 

competency training is 

incorporated into the 

organization’s required indepth orientation for new 

hires. 

40 
CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

Changes to structure, staffing, and resources 

•	 Strategies to recruit, retain, and promote a diverse set of leaders at all levels that reflect 

the demographics of those you serve 

•	 Informed and committed champions for cultural competency 

•	 Staff responsible for identifying opportunities, resources, and processes for leadership and 

staff training and mentorship 

•	 Changes in budget to support the development of new policies and procedures, staff 


training, and related costs
 

•	 Allocating resources to train current staff as interpreters if they express interest and meet 

qualifications; and to support mentor relationships. 

Changes to processes and practices 

•	 Advertising job opportunities and recruiting potential employees in targeted foreign 


language and minority health professional associations, publications, and convenings
 

•	 Relationships with businesses, public schools, and other stakeholders to create a pipeline 

for diverse staff and provide them with the support and resources necessary to meet job 

requirements 

•	 Processes that encourage dialogue about meeting the needs of diverse populations and 

preventing discrimination 

•	 Changes to staff training, both for new hires and existing employees, that uses adult 

learning principles (e.g., exploration of one’s own cultural background and the 

cultural backgrounds of the populations you serve), elements of effective cross-cultural 

communication and use of language services, and strategies for cross-cultural conflict 

resolution 

41 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

•	 Strategies for collecting race, ethnicity, sex, language, and disability 

status data in a sensitive manner 

•	 Evaluation 

– ongoing assessment of staff demographics and promotion 

demographics 

– evaluation of education and training, including pre- and postassessments 

– changes to staff performance evaluation to assess cultural and 

linguistic competency. 

Finally, your logic model should list the anticipated outputs and outcomes 

of these activities. For Standards related to leadership, governance, and 

workforce, these may include 

•	 a culturally and linguistically representative workforce at all levels 

•	 organizational leadership and staff exhibiting nondiscriminatory and 

culturally/linguistically competent attitudes, knowledge, and skills 

•	 database of race, ethnicity, sex, language, and disability status of 


consumers.
 

IMPLEMENTATION 

IN ACTION: 

Staff Diversity at the 

Great Brook Valley 

Health Center 

(Standard 3) 

The Great Brook Valley 

Health Center (GBVHC) in 

Worcester, Mass., is very 

diverse, with a staff that 

speaks 29 languages and 

comes from 36 countries. 

When GBVHC was having 

difficulty finding Hmong 

interpreters, leadership 

contacted the school 

system in a community 

where there was an 

existing Hmong population 

to obtain qualified 

applicants. Leadership is 

also committed to sharing 

knowledge and resources 

with the surrounding 

community and other 

providers. 

42 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

CONTEXT, 

ANTECEDENTS, 

AND INPUTS 

PROPOSED CHANGES 

AND STRATEGIES FOR 

IMPLEMENTATION OUTPUTS 

OUTCOMES AND IMPACTS 

SHORT TERM LONGER TERM 

Governance, 

Leadership, 

and 

Workforce 

(Standards 

2–4) 

A mismatch 

between the 

cultural and 

linguistic 

characteristics 

of the 

population(s) 

served and 

the current 

workforce 

demographics 

and 

promotion 

demographics 

Organization 

makes changes to 

its staff recruitment 

process, such as 

advertising job 

opportunities in 

targeted foreign 

languages and 

minority health 

professional 

association 

publications 

A more 

culturally and 

linguistically 

representative 

workforce 

Organizational 

leadership 

and staff 

exhibiting nondiscriminatory 

and culturally/ 

linguistically 

competent 

attitudes, 

knowledge, 

and skills 

Improved 

access to 

care among 

culturally 

diverse 

consumers 

43 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

HOW CAN I SHAPE MY EVALUATION TO ASSESS IMPLEMENTATION 

AND EFFECTIVENESS OF THESE STANDARDS? 

In Chapter 2, we discussed a set of overarching evaluation questions that will help you to assess 

the impact of the National CLAS Standards on your organization and the populations you serve. 

As you review these questions, think about what they mean in the context of Standards 2–4, 

which relate to governance, leadership, and workforce. 

In the short term, for example, think about how infusing cultural competency throughout 

your workforce and leadership would increase consumer engagement with care and follow-up 

visits. Or think about how implementing training processes would increase staff knowledge of 

culturally and linguistically appropriate care. In the long term, how have changes to processes 

and policies produced greater awareness of and workforce buy-in of culturally and linguistically 

appropriate care and services? How has the infusion of cultural competency and health equity 

principles improved trust and engagement between individuals seeking care and your staff over 

time? These pathways may help you to think about important process, implementation, and 

outcome measures you wish to capture in your evaluation. 

In Table 3, we present some example metrics you can use to assess your progress toward 

implementing practices that align with the governance, leadership, and workforce Standards, 

as well as the impact of those processes on your organization and those you serve. This is not 

a comprehensive list, but it will help you get started and may complement metrics you already 

collect. Additional information on the measures, including links to survey documents, can be 

found in Chapter 4. 

44 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

TABLE 3. METRICS AND WAYS OF ASSESSING STANDARDS 2–4 

EXAMPLE METRIC	 DESCRIPTION
 

CAHPS Cultural 

Competence 

Item Set: 

patient-provider 

communication, 

complementary 

and alternative 

medicine, 

experiences of 

discrimination, 

and linguistic 

competency 

measures 

CAHPS Cultural Competence items are a set of supplemental items for the CAHPS 

Clinician/Group Survey that ask consumers about their experiences with the cultural 

competence of an organization that provided them services. CAHPS Cultural Competence 

items were designed for medical practices and clinics, but questions could be applied to 

diverse health care and public health settings. Scores are calculated for five item sets. 

The patient-provider communication, complementary and alternative medicine, 

experiences of discrimination, and linguistic competency items are most relevant for this 

group of Standards and assess such measures as 

•	 understanding of provider instructions based on providers’ communication style 

•	 communication with provider about use of acupuncture, natural herbs, and the like 

•	 patient experiences with discrimination 

•	 whether language services were offered. 

C-CAT workforce 

development, 

leadership 

commitment, 

cross-cultural 

communication, 

and performance 

evaluation 

domains 

The C-CAT provides assessments of consumers, staff, and organizational leadership to 

comprehensively measure the implementation and outcomes of providing language 

services. C-CAT has been validated in diverse health care settings nationwide. C-CAT 

scores are calculated on nine domains. 

A number of domains are relevant to this group of Standards (e.g., workforce 

development, leadership commitment, cross-cultural communication, and performance 

evaluation) and include items assessing 

•	 written policies on culturally appropriate communication 

•	 senior leadership encouragement of discussions with consumers about cultural and 

spiritual beliefs 

•	 staff training on asking patients about their racial/ethnic background in a culturally 

appropriate way 

•	 effectiveness of staff training for improving patient communication 

•	 patient perceptions of staff understanding their culture 

•	 performance evaluation system’s capacity to assess staff’s cross-cultural communication 

skills. 

45 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

GOVERNANCE, LEADERSHIP, AND WORKFORCE: Standards 2–4 

TABLE 3. METRICS AND WAYS OF ASSESSING STANDARDS 2–4 

EXAMPLE METRIC	 DESCRIPTION
 

Cultural 

Competency 

Implementation 

Measure, 

commitment to 

serving a diverse 

population, 

leadership 

diversity, 

dedicated staff and 

resources, reward 

systems, and 

clinical encounter 

subdomains 

The Cultural Competency Implementation Measure is an organizational survey designed 

to assist health care organizations in identifying the degree to which they are providing 

culturally competent care and addressing the needs of diverse populations. The Cultural 

Competency Implementation Measure was designed for use in diverse health care 

settings. Scores are calculated for 12 subdomains. 

A number of subdomains are relevant to this group of Standards (e.g., commitment to 

serving a diverse population, leadership diversity, dedicated staff and resources, reward 

systems, and clinical encounter) and include items assessing 

•	 organization’s mission, vision, and goals for a commitment to cultural competency 

•	 documentation of fiscal support for culturally competent policies and practices 

•	 strategies for recruiting, retaining, and promoting a diverse staff at all levels of the 

organization, including upper management 

•	 job performance evaluation criteria for cultural competence improvement goals 

•	 collection of patient information on cultural beliefs (e.g., religion, nationality,
 

ethnicity)
 

Screening for 

preferred spoken 

language for 

health care 

measure 

The screening for preferred spoken language for health care measure is used to assess 

the percentage of patient visits and admissions where preferred spoken language for 

health care is screened and recorded. It relies on administrative claims, electronic health 

records, or other records of consumer visits. The measure was designed for use by 

hospitals and outpatient clinics, but could be applied across health care settings where 

patient records are kept. 

It is calculated by determining the number of hospital admissions, visits to the emergency department, and outpatient visits where preferred spoken language for health 

care is screened and recorded and dividing that number by the total number of hospital admissions, visits to the emergency department, and outpatient visits. 

46 
CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

Standard 5. Offer language assistance to individuals who have limited English 

proficiency and/or other communication needs, at no cost to them, to facilitate timely 

access to all health care and services. 

Standard 6. Inform all individuals of the availability of language assistance services 

clearly and in their preferred language, verbally and in writing. 

Standard 7. Ensure the competence of individuals providing language assistance, 

recognizing that the use of untrained individuals and/or minors as interpreters should 

be avoided. 

Standard 8. Provide easy-to-understand print and multimedia materials and signage 

in the languages commonly used by the populations in the service area. 

WHY ARE THESE STANDARDS IMPORTANT? 

Language assistance services are mechanisms used to facilitate communication with individuals 

who do not speak English, those who have limited English proficiency, and those who are blind, 

deaf, or with hearing loss. These services include on-site interpreters, bilingual staff, or use of 

remote interpreting systems, such as telephone or video interpreting for both spoken languages 

and sign languages, as well as the translation of written materials or signage, or braille material. Standard 5 highlights that the provision of these services is critical to ensuring consumer 

satisfaction, safety, quality of care, and improved outcomes. By using quality language services, 

your organization will facilitate effective and accurate communication between your staff and 

consumers, regardless of their language proficiency. Language assistance also improves the qual47 
CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

ity of services you provide and promotes patient safety by facilitating conversations regarding 

prevention, symptoms, diagnosis, treatment, and other issues. Additionally, your organization 

may be required to offer language assistance services in order to receive some federal funds. 

Standard 6 summarizes the importance of notifying consumers that language services are 

available to them at no cost. Because many consumers may not be aware that services exist, staff 

may inform consumers of language services speaking to people in-person or over the phone, 

using language identification tools (“I speak” cards), or publishing multimedia materials. Since 

staff are crucial conduits of information about language services to consumers, all members of 

the organization should be fully aware of the communication and language assistance services 

available, and all related organizational policies and procedures, and should be offered training 

and continuing education about these services. 

Standard 7 illustrates that it is important for organizations to ensure that staff or contractors 

tasked with interpretation and language services have the ability and skills to provide highquality services to your consumers. These qualifications often extend beyond language ability 

to include knowledge of health concepts, cultural competency, and skills in applying interpreter 

standards, protocols, and ethics. Doing so can minimize the risk of miscommunication and 

the potential for medical errors and poor quality of care when ad hoc interpreters or family 

members are used to interpret. Using ad hoc interpreters and family members may also violate 

consumers’ preferences for confidentiality and privacy and may be distressing to family or 

friends tasked with interpretation. 

Standard 8 focuses on the availability of print and multimedia materials that help to ensure 

that the people you serve—including those with limited English proficiency (LEP) and low health 

literacy—can read, comprehend, and act on written materials. Unfortunately, most clinical 

48 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

and health promotion information is written at too high a level for the average person to 

understand. Those with health literacy challenges are disproportionately represented in minority 

populations, which may lead to worsening health disparities. Your organization can become 

more “health literate” by designing and distributing print, audiovisual, and social media content 

that is easy to understand and act on. Such materials use culturally appropriate graphics, employ 

user-friendly design, focus on providing clear directions to the consumer, and do not use jargon. 

They should also be available in common non-English languages spoken in the community. 

Health materials, including signage, should supplement in-person communication to reinforce 

the messages your staff conveys, rather than replacing in-person communication. 

Your organization can use a variety of approaches for addressing Standards 5–8, depending 

on the type of services you offer. Further, your organization may choose to create different types 

of materials, forms, and signs depending on the type of services you offer. As is discussed for all 

of the National CLAS Standards, it is important to monitor the quality and use of services. 

49 
CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

By addressing these Standards, you will: 

Standard 5 

•	 ensure that consumers with LEP or other communication needs receive equitable access to 

services 

•	 help consumers understand their health care and service options and allow them to 


participate in health care decisionmaking
 

•	 increase satisfaction with care 

•	 improve adherence to recommendations and treatments 

•	 improve consumer safety and reduce miscommunications that contribute to medical errors 

•	 comply with requirements, such as Title VI of the Civil Rights Act of 1964, the Americans 

with Disabilities Act of 1990, and other relevant policies. 

Standard 6 

•	 inform individuals with LEP in their preferred language that language services are readily 

available at no cost to them 

•	 facilitate access to language services. 

Standard 7 

•	 provide accurate and effective communication between individuals and providers 

•	 reduce misunderstanding, dissatisfaction, omission of vital information, misdiagnoses, 

inappropriate treatment, and patient safety issues because of reliance on staff or 

individuals that lack interpreter training 

•	 empower individuals to negotiate and advocate on their own behalf for important 


services via effective and accurate communication with health and health care staff
 

50 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

Standard 8 

•	 ensure that readers of other languages and individuals with various 

health literacy levels are able to access care and services 

•	 provide access to health-related information and facilitate 

comprehension of and adherence to instructions and health plan 

requirements 

•	 offer an effective way to communicate with large numbers of people 

and supplement information provided orally by staff members. 

HOW COULD I SHAPE MY LOGIC MODEL TO REFLECT 

THESE STANDARDS? 

In Chapter 2, the idea of a logic model was introduced. Logic models can 

help you think through your evaluation in greater detail to ensure you 

measure what is important. In this section, we provide some ideas for how 

you might think about building out a logic model to evaluate your implementation of Standards 5–8. Every organization is different, but here are 

examples of things to consider as you tailor your logic model to implement 

and assess activities that aim to meet standards related to communication 

and language assistance. 

IMPLEMENTATION 

IN ACTION: 

Healthcare Interpreter 

Certificate Program 

(Standard 7) 

Kaiser Foundation Health Plan 

in Oakland, Calif., established 

a college-level training 

program with didactics and 

fieldwork designed to provide 

accreditation standards for 

interpreters serving LEP 

members and the community 

at large. Through national 

dissemination of the program, 

more than 100 college-level 

instructors across the country 

and numerous staff have 

been trained and certified. 

Evaluation results suggest that 

providers who used trained 

interpreters overwhelmingly 

preferred them over untrained 

interpreters (e.g., family 

members and bilingual 

staff), and patients could 

differentiate between trained 

versus untrained interpreters, 

favoring trained interpreters 

significantly. 

51 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

Consider, for example, the context, antecedents, and inputs that highlight a need for 

language assistance with the population you serve: 

•	 interpretation and translation needs at various points of contact between staff and 

consumers 

•	 availability of printed materials to aid in translation and interpretation (e.g., handouts for 

patients, signage for waiting rooms, legal forms) and appropriate content 

•	 availability of materials or language services in the region, including bilingual staff or 

dedicated language assistance (e.g., a contract interpreter or video remote interpreting). 

Implementation of National CLAS Standards often requires changes to or the development of 

new policies, procedures, and staffing. Your logic model should include the proposed changes 

and strategies to implement those changes that you have identified and implemented. Some 

examples related to Standards 5–8 are listed below. 

Changes to organizational policies 

•	 Development of a written policy that requires the use of qualified language services (e.g., 

prohibits the use of family members or friends as interpreters) 

•	 Development of a policy around plain language and the creation of documents that 

demonstrate best practices in clear communication and information design 

•	 Development of a written policy that describes your organization’s approach to informing 

consumers of language services. 

52 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

Changes to structure, staffing, and resources 

•	 Changes to staff responsibilities, ensuring that appropriate staff 

have ownership over materials development, needs assessment, and 

dissemination 

•	 Changes in budget to support translation of materials, development of 

plain language forms, printing and production of materials, and related 

costs 

•	 Addition of technology required to efficiently support interpretation 

services (e.g., video remote interpretation) 

•	 Use of signs, materials, and multimedia resources to reflect the 

languages regularly encountered by your organization at various 

points of entry and intake or areas where clinical or educational work is 

performed. Include culturally appropriate visuals to convey messages at 

low literacy levels. 

IMPLEMENTATION 

IN ACTION: 

Remote Video Voice 

Medical Interpretation 

Project (Standard 5) 

Contra Costa County, Calif., 

Health Services initiated 

a partnership among four 

local hospitals to develop 

a remote and mobile voice 

system supported by voice 

call centers that provide 

services in two languages. 

This partnership tripled the 

number of translations per 

day. This has generated a 

cost savings to the hospitals 

of $0.80 per minute, which 

in one month totaled 

$25,000. 

53 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

Changes to processes and practices 

•	 Changes to workflow, including how preferred language will be assessed and recorded (e.g., 

in patient charts, client service records), processes for sending for or contacting interpreters 

(on-site or remote), and location of translated materials 

•	 Changes to employee and/or contractor assessments to ensure language proficiency and 

interpreting skills of individuals providing language services (e.g., use language-proficiency 

scales from the American Council on the Teaching of Foreign Languages or Interagency 

Language Roundtable and a valid and reliable tool to assess interpreting skills) 

•	 Create forms that are easy to fill out and offer assistance in completing forms 

•	 Test materials with target audiences (e.g., with focus groups, community partners) 

•	 Establish processes for periodically reevaluating and updating materials. 

Finally, your logic model should list the anticipated outputs and outcomes of these activities. 

For Standards related to communication and language assistance, these may include: 

•	 availability of high-quality interpretation services, including 

– consumer awareness of the availability of no-cost interpretation 

– frequency of use of interpretation services 

– wait times for consumers to receive interpretation services 

•	 staff knowledge of how to access communication and language assistance 

•	 availability of professionally translated written consumer materials. 

54 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

Table 4 illustrates an example of how to align the elements of the logic model using the 

just-mentioned points, which makes it easier to develop or choose metrics and evaluation questions. 

TABLE 4. ALIGNING THE LOGIC MODEL 

CONTEXT, 

ANTECEDENTS, 

AND INPUTS 

PROPOSED CHANGES 

AND STRATEGIES FOR 

IMPLEMENTATION OUTPUTS 

OUTCOMES AND IMPACTS 

SHORT TERM LONGER TERM 

Communication 

and Language 

Assistance 

(Standards 5–8) 

Population(s) 

served have 

a clearly 

identified 

need for 

language 

services at 

various points 

of contact 

Workflow changes 

are implemented 

that improve the 

capacity to identify 

when a language 

service need is 

present 

Organization 

provides 

equitable, 

effective, and 

high-quality 

services to 

consumers 

with language 

service needs 

Improved 

two-way 

communication 

between 

consumers and 

health care 

staff 

Improved 

patient health 

outcomes 

55 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

COMMUNICATION AND LANGUAGE ASSISTANCE: 

Standards 5–8 

HOW COULD I SHAPE MY EVALUATION TO ASSESS IMPLEMENTATION 

AND EFFECTIVENESS OF THESE STANDARDS? 

In Chapter 2, we discussed a set of overarching evaluation questions that will help you to assess 

the impact of the National CLAS Standards on your organization and the populations you serve. 

As you review these questions, think about what they mean in the context of Standards 5–8, 

which relate to communication and language services. 

In both the short and the long terms, you should be able to observe changes within your 

organization and among the consumers you serve. In the short term, for example, think about 

how access to interpreters would help consumers with language-service needs navigate the 

services you provide. Or think about how implementing language services would contribute 

to improved two-way communication between consumers and your staff. In the long term, 

how would offering interpretation and translated materials contribute to the capacity of your 

organization to serve a diverse population? How has providing language services impacted 

consumer satisfaction over time? These pathways may help you think about important process, 

implementation, and outcome measures you wish to capture in your evaluation. 

Table 5 presents some example metrics you can use to assess your progress toward 

implementing practices that align with the communication and language Standards, as well 

as the impact of those processes on your organization and those you serve. This is not a 

comprehensive list, but it will help you get started and may complement metrics you already 

collect. Additional information on the measures, including links to survey documents, can be 

found in Chapter 4. 

56 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

TABLE 5. METRICS AND WAYS OF ASSESSING STANDARDS 5–8 

EXAMPLE METRIC	 DESCRIPTION 

CAHPS Cultural 

Competence Item 

Set, access to 

language services 

measure 

CAHPS Cultural Competence items are a set of supplemental items for the CAHPS Clinician/ 

Group Survey that ask consumers about their experiences with the cultural competence 

of an organization that provided them services. CAHPS Cultural Competence items were 

designed for medical practices and clinics, but questions could be applied to diverse health 

care and public health settings. Scores are calculated for five item sets. 

The linguistic competency (access to language services) items are most relevant for this 

group of Standards and assess: 

•	 respondent English proficiency 

•	 whether language services were offered free of charge and how long consumers 

had to wait for services 

•	 frequency of use of language services 

•	 satisfaction with language services. 

CAHPS Item Set for 

Addressing Health 

Literacy, all item 

sets 

CAHPS Addressing Health Literacy items are a set of supplemental items for the CAHPS 

Clinician/Group Survey that ask consumers about their experiences with receiving materials 

and instructions that were easy to understand. CAHPS Addressing Health Literacy items 

were designed for medical practices and clinics, but questions could be applied to diverse 

health care and public health settings. Scores are calculated for five item sets. 

There are items in all five item sets relevant to these Standards that assess: 

•	 use of pictures, drawings, models, or videos to convey information 

•	 consumer ability to understand and fill out forms 

•	 consumer ability to understand information about elements in health care, such as 

disease management and medicines. 

57 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

EXAMPLE METRIC	 DESCRIPTION 

Communication 

Climate 

Assessment Toolkit 

(C-CAT), language 

services domain 

The C-CAT provides assessments of consumers, staff, and organizational leadership to 

comprehensively measure the implementation and outcomes of providing language 

services. C-CAT has been validated in diverse health care settings nationwide. C-CAT scores 

are calculated on nine domains. 

The language services domain is most relevant for this group of Standards and includes 

items assessing 

•	 existence and awareness of policies and processes governing the use of interpreters 

•	 availability and frequency of use of language services (translated materials and 

interpreters) 

•	 frequency of miscommunication between staff and consumers 

•	 whether language services were offered free of charge 

•	 satisfaction with language services 

• perceptions of communication skills of staff
 

• overall satisfaction with care.
 

Cultural 

Competency 

Implementation 

Measure, language 

access subdomain 

The Cultural Competency Implementation Measure is an organizational survey designed 

to assist health care organizations in identifying the degree to which they are providing 

culturally competent care and addressing the needs of diverse populations. The Cultural 

Competency Implementation Measure was designed for use in diverse health care settings. 

Scores are calculated for 12 subdomains. 

The language access subdomain is most relevant for this group of Standards and includes 

items assessing 

•	 whether language services policies have been reviewed and updated 

•	 whether language services are available in different areas of the organization 

•	 existence of procedures for effective language assistance communication via
 

multiple modes (telephone, in-person).
 

58 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

COMMUNICATION AND LANGUAGE ASSISTANCE: Standards 5–8 

EXAMPLE METRIC DESCRIPTION 

Patients receiving 

language services 

supported by 

qualified language 

services providers 

measure 

This measure is used to assess the percentage of LEP patients receiving both initial assessment and discharge instructions supported by assessed and trained interpreters or from 

bilingual providers and bilingual workers/employees assessed for language proficiency. 

It relies on administrative claims, electronic health records, or other records of consumer 

visits. This measure was designed for use in medical practices and clinics, but questions 

could be applied to diverse health care and public health settings. 

It is calculated by determining the number of LEP patients with documentation that 

received the initial assessment and discharge instructions and were supported by trained 

and assessed interpreters and dividing that number by the total number of patients that 

stated a preference to receive their spoken health care in a language other than English. 

Screening for 

preferred spoken 

language for 

health care 

measure 

The screening for preferred spoken language for health care measure is used to assess 

the percentage of patient visits and admissions where preferred spoken language for 

health care is screened and recorded. It relies on administrative claims, electronic health 

records, or other records of consumer visits. The measure was designed for use by hospitals and outpatient clinics, but could be applied across health care settings where patient 

records are kept. 

This measure is calculated by determining the number of hospital admissions, visits to 

the emergency department, and outpatient visits where preferred spoken language for 

health care is screened and recorded and dividing that number by the total number of 

hospital admissions, visits to the emergency department, and outpatient visits. 

59 
 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

Standard 9. Establish culturally and linguistically appropriate goals, policies, and 

management accountability, and infuse them throughout the organization’s planning 

and operations. 

Standard 10. Conduct ongoing assessments of the organization’s CLAS-related 

activities and integrate CLAS-related measures into measurement and continuous 

quality improvement activities. 

Standard 11. Collect and maintain accurate and reliable demographic data to 

monitor and evaluate the impact of CLAS on health equity and outcomes and to 

inform service delivery. 

Standard 12. Conduct regular assessments of community health assets and needs 

and use the results to plan and implement services that respond to the cultural and 

linguistic diversity of populations in the service area. 

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

policies, practices, and services to ensure cultural and linguistic appropriateness. 

Standard 14. Create conflict and grievance resolution processes that are culturally 

and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. 

Standard 15. Communicate the organization’s progress in implementing and 

sustaining CLAS to all stakeholders, constituents, and the general public. 

60 
 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

WHY ARE THESE STANDARDS IMPORTANT? 

To fully integrate CLAS, you may need to rethink the way you work, from your front desk to 

your leadership team; the principles that guide your organization; which outside organizations 

you partner with to implement CLAS; and the ways in which you measure success. Standard 9 

illustrates that establishing goals, policies, and management accountability that promote CLAS 

throughout your organization will ensure that your organization is culturally and linguistically 

competent at every point of contact. Doing so will also help to tie CLAS to your organizational 

priorities, such as consumer satisfaction, safety, and outcomes, which will be key to ensuring that 

the Standards are fully implemented over time. This integrated approach also demonstrates that 

cultural and linguistic competency is integral to the way you run your organization. 

Standard 10 highlights the importance of assessing progress toward your organization’s CLAS 

goals. A key element of successfully implementing the National CLAS Standards for cultural 

and linguistic competency involves a continuous quality-improvement process, including an 

assessment phase, a planning phase, an implementation phase, and an evaluation phase. These 

assessments can range in intensity from relatively brief organizational checklists to in-depth 

assessments with structured and formal input from stakeholders, consumers, and/or staff. 

Methods can range from informal interviews to using validated surveys across the organization. 

In general, integrating measures related to cultural and linguistic competency into your existing 

assessment efforts and CQI programs will help you learn whether CLAS delivery processes are 

producing the desired results. Absent these measures, you may not be able to demonstrate 

the effectiveness of CLAS delivery nor will you be able to identify ways to improve CLAS 

implementation. 

61 
 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

Standard 11 focuses on understanding the population you serve to plan your implementation 

appropriately. The availability of demographic data, particularly on race and ethnicity, is the 

first step for your organization to be able to demonstrate the effectiveness of CLAS in reaching 

your goal of delivering quality, equitable services and, ultimately, in reducing disparities 

and improving health equity. Your organization should train staff in cultural and linguistic 

competency to collect key data from consumers in a sensitive manner, including demographic 

information such as race, ethnicity, sex, language, and disability status. You should also consider 

the ways in which you plan to share data across departments and throughout the continuum 

of services you provide. These data will help you to establish the foundation for cultural and 

linguistic competency, become more responsive to cultural preferences, tailor services to 

diverse needs, and use your resources more cost-effectively. Thus, one purpose of collecting and 

maintaining accurate demographic data is to link the data with other measures you collect and 

use them in ongoing monitoring, evaluation, and CQI activities. For example, you might track 

use and satisfaction with different services by race/ethnicity to make staffing decisions or target 

quality-of-care improvement efforts. 

Standard 12 highlights the value of conducting regular assessments of community health 

needs and assets. Knowing your community—including its needs, already-available resources, 

and service gaps—will help you to understand how to provide the best service and value. Needs 

assessments can help your organization gain cultural knowledge about community health beliefs 

and attitudes, as well as the specific interventions that would be of help to community members. 

By assessing existing resources in the community, your organization can avoid duplication of 

services and better connect consumers to those resources. It is important to partner with key 

62 
 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

stakeholders from the populations you serve to collect information for your needs and resource 

assessments and to help promote the culturally and linguistically competent services you plan 

to implement. Over time, your organization can use the information gained from ongoing 

assessment to develop appropriate services and evaluate access to and use of those services, 

including disparities in care and the potential for improving health equity. 

Standard 13 builds on the idea of conducting community needs assessments to creating 

meaningful partnerships with community members in your service area. Community partnerships 

are essential to help your organization be culturally and linguistically competent: Only through 

meaningful community partnerships can your organization truly understand the needs of the 

diverse populations you serve, appropriately allocate resources, and develop an accountable 

system that provides equitable culturally and linguistically appropriate care and services. When 

it comes time to conduct planning activities, quality improvement assessments, or evaluations, 

seeking community input will help you to understand your organization’s reputation and 

the best ways to expand the reach and impact of your services. It will also prevent your staff 

from recommending activities that are culturally inappropriate or infeasible for consumers. 

Community involvement can take many forms, from forming community steering committees 

and coalitions, to conducting key interviews and focus groups, to collaborating with cultural 

brokers and lay community health workers. 

Standard 14 addresses the importance of creating conflict- and grievance-resolution processes 

that are culturally and linguistically appropriate. One of the reasons that health disparities 

exist today is the existence of discriminatory and inequitable practices by health organizations, 

although often unintentional and unconscious. These inequitable practices may be embedded in 

63 
CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: Standards 9–15 

systems’ policies and procedures. Discrimination based on race, ethnicity, sex, age, socioeconomic 

status, sexual orientation, gender identity, and other characteristics make it difficult to provide 

quality care and services, which means that culturally and linguistically competent conflict 

prevention and resolution are vital parts of advancing health equity. Even if your organization 

makes a commitment to cultural and linguistic competency (e.g., through adoption of other 

National CLAS Standards), it is inevitable that individuals will have conflicts and grievances, 

including differences related to informed consent and advance directives to difficulties in 

accessing services or denial of services to discriminatory treatment. Your organization should 

anticipate and be responsive to the differences that arise among individuals and your staff. You 

can institutionalize this thinking through implementing training for staff and leadership on 

how to listen and respond in conflict situations (as described in more detail in Standard 4), by 

incorporating cultural sensitivity into existing feedback procedures, and by actively seeking input 

from community members (as addressed in the other Standards in this group). 

Standard 15 emphasizes the need to communicate your organization’s progress in 

implementing and sustaining the National CLAS Standards to all stakeholders, constituents, 

and the public. Communicating about progress can serve many purposes when it comes to 

developing a more culturally and linguistically appropriate organization. It can allow your 

organization to share its accomplishments and identify areas for improvement; it can help you 

to institutionalize CLAS by prompting your organization to think critically about, or better yet, 

formally evaluate, the extent to which you have implemented each Standard; it will help hold 

you accountable to the communities you aim to serve; and it also helps organizations learn 

from one another about new ideas and promising practices for implementing CLAS in different 

communities and settings. There are several ways in which you can communicate about your 

64 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

organization’s progress, all of which build on the other Standards in the engagement, continuous 

improvement, and accountability category. You can report results of evaluations (Standard 10), 

describe the data collected and communities served (Standard 11), share the results of community 

health assessments (Standard 12), or describe the partnerships you have built with community 

members (Standard 13). 

Your organization will choose to set different goals, create your own policies, and collect 

different types of data in different ways depending on the populations you serve and the type of 

services you offer. As is discussed for all National CLAS Standards, it is important to monitor the 

quality and use of services. 

By addressing these Standards, you will: 

Standard 9 

•	 make CLAS central to your organization’s service, administrative, and supportive functions 

•	 integrate CLAS throughout your organization (including the mission) and highlight its 

importance through specific goals 

•	 link CLAS to other organizational activities, including policy, procedures, and 


decisionmaking related to outcomes accountability.
 

Standard 10 

•	 assess and improve the extent to which health care services are provided equitably 

•	 assess the value of CLAS-related activities relative to the fulfillment of governance, 

leadership, and workforce responsibilities 

•	 ensure equal allocation of organizational resources 

•	 improve service planning to enhance access and coordination of care. 

65 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

Standard 11 

•	 assess performance and monitor progress in implementing the Standards 

•	 accurately identify population groups within a service area 

•	 tailor and improve services based on the people you serve 

•	 monitor individual needs, access, use, quality of care, and outcome patterns. 

Standard 12 

•	 determine the service assets and needs of the populations in your service area (needs 

assessment) 

•	 identify all of the services available and unavailable to the populations in your service area 

(resource inventory and gap analysis) 

•	 determine what services to provide and how to implement them based on the results of 

the community assessment 

•	 ensure that your organization obtains demographic, cultural, linguistic, and 

epidemiological baseline data (both quantitative and qualitative) and updates the data 

regularly to better understand the populations in your service area. 

Standard 13 

•	 provide responsive and appropriate service delivery to a community 

•	 ensure that services are informed and guided by community interests, expertise, and needs 

•	 increase use of services by engaging individuals and groups in the community in the 

design and improvement of services to meet their needs and desires 

•	 create an organizational culture that leads to more-responsive, efficient, and effective 

services and accountability to the community 

•	 empower members of the community to become active participants in the health and 

health care process. 66 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

Standard 14 

•	 facilitate open and transparent two-way communication and feedback mechanisms 

between individuals and organizations 

•	 anticipate, identify, and respond to cross-cultural needs 

•	 meet federal and/or state level regulations that address topics such as grievance 

procedures, the use of ombudspersons, and discrimination policies and procedures. 

Standard 15 

•	 convey information to intended audiences about efforts and accomplishments in meeting 

the National CLAS Standards 

•	 learn from other organizations about new ideas and successful approaches to 

implementing the National CLAS Standards 

•	 build and sustain communication on CLAS priorities and foster trust between the 

community and your organization 

•	 meet community benefits and other reporting requirements, including accountability for 

meeting health care objectives in addressing the needs of diverse individuals or groups. 

67 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

HOW COULD I SHAPE MY EVALUATION TO ASSESS 

IMPLEMENTATION AND EFFECTIVENESS OF THESE 

STANDARDS? 

In this section, we provide some ideas for how you might think about 

building out a logic model to evaluate your implementation of these 

CLAS Standards related to goals and policies, assessing population needs 

and tailoring services, developing partnerships, resolving conflicts, and 

communicating your success. Standard 10 is unique in relation to the 

other National CLAS Standards in that the Standard itself relates to implementing measurement activities. As such, the logic models you have 

developed for other National CLAS Standards will help you as you work 

to implement Standard 10 and should be referenced often throughout 

the process. Below are examples of things to consider as you tailor your 

logic model to implement and assess activities that aim to meet these 

Standards. 

IMPLEMENTATION 


IN ACTION: 


Lowell Community Health Center 


(Standard 13) 


The Lowell Community Health Center 

(LCHC) in Lowell, Mass., offers services 

to an ethnically and economically 

diverse community. To better meet 

the needs of the community, LCHC 

is committed to partnering with 

grassroots organizations in every area 

of service delivery by 

•	 building subcontracting 

opportunities for community 

partners into grants. Currently, 

ten community-based 

organizations have subcontracts 

with LCHC 

•	 sponsoring several community 

advisory groups, including the 

African Advisory Council, the 

Southeast Asian Task Force, 

and Portuguese and Spanishspeaking Promotores. 

LCHC also engaged residents in the 

Metta Health Center design process, 

asking key members of the local 

Southeast Asian community, “If you 

could design the ideal health center, 

what would it look like?” It also relies 

on ongoing communication with 

cultural brokers for cultural insights 

and feedback. 

68 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

Consider, for example, the context, antecedents, and inputs that highlight a need to change 

goals and policies, collect accurate data, and partner and communicate with outside entities: 

•	 current organizational mission, goals, policies, and accountability frameworks 

•	 cultural and linguistic characteristics of the population(s) you serve 

•	 current measurement and assessment activities (e.g., consumer surveys, staff performance 

evaluations, accountability frameworks) and gaps where new measurement processes will 

need to be developed 

•	 your organization’s capacity to collect, store, and analyze data needed to assess CLAS 

Standard implementation 

•	 landscape of potential partners 

•	 your organization’s capacity to develop partnerships and disseminate findings. 

Implementation of National CLAS Standards often requires changes to or the development of 

new policies, procedures, and staffing. Your logic model should include the activities that you 

have adopted and implemented. Some examples related to Standards 9–15 are listed below. 

69 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

Changes to organizational policies 

•	 Having a written policy that reinforces your organization’s commitment to 

– assessing progress of CLAS-related activities 

– collecting reliable demographic data 

– ensuring that data is not used to discriminate 

– developing and maintaining partnerships 

– disseminating results. 

Changes to structure, staffing, and resources 

•	 Staff who are responsible for identifying opportunities, resources, and processes for 

monitoring and evaluation, as well as partnership development 

•	 Changes in budget to support the development of new policies and procedures, staff 

training, and related costs for measurement, partnership, and dissemination 

•	 Allocating resources to evaluation, partnership, and dissemination activities 

•	 Identifying internal and external champions; staff responsible for leading strategic planning 

activities that incorporate CLAS and encouraging full-scale implementation. 

70 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

Changes to processes and practices 

•	 Creating plans for developing CLAS throughout your organization’s goals, 

policies, and practices with accountability frameworks and associated 

measures and identifying the specific CLAS Standards you plan to 

implement 

•	 CLAS integration into CQI processes (e.g., organizational assessments,
 

CLAS-oriented surveys for consumers, focus groups with staff and
 

consumers to identify barriers to CLAS implementation, CLAS-related
 

questions in staff orientation materials and yearly reviews)
 

•	 Holding organizational retreats to identify goals, objectives, and timelines 

to provide culturally and linguistically appropriate services, using data 

gathered from evaluations to reimagine identity, mission, operating 

principles, service focus, budget, and quality improvement activities to 

focus on CLAS 

•	 Changes in accountability mechanisms throughout the organization, 

including staff evaluations, individuals’ satisfaction measures, and quality 

improvement to assess CLAS goal achievement (e.g., cultural competency, 

communication skills) 

•	 Processes for collecting demographic information at different points of 

entry and sharing across your organization (e.g., enrollment data included 

on consumer records) 

•	 Staff training on strategies and survey instruments for collecting race, 

ethnicity, sex, language, and disability status data relevant to your 

community in a sensitive, reliable manner (e.g., HHS Data Collection 

Standards; using self-identification and allowing for more than one 

category to be selected). 

IMPLEMENTATION 

IN ACTION: 

Boston Public Health 

Commission’s DataCollection Efforts 

(Standard 11) 

The Boston Public Health 

Commission undertook a 

citywide health disparities 

initiative that required 

the collection of data on 

consumer race/ethnicity and 

other potentially sensitive 

information. Commission 

leadership noted that their staff 

was initially reluctant to collect 

patient data, and patients 

were hesitant to provide the 

information when asked. This 

prompted the Commission to 

institute sensitivity training and 

provide staff with scripts to use 

that included a description of 

what the information would be 

used for: to provide equitable 

care. After implementation of 

the training, they found that 

patients were more likely to 

share information because they 

understood the purpose of data 

collection. 

71 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

Finally, list the anticipated outputs and outcomes of these activities. Here are some examples: 

•	 Organizational mission, vision, goals, and accountability frameworks that are integrated 

with CLAS principles, including identification of specific National CLAS Standards for implementation 

•	 Structure, processes, and measures for ongoing assessment of CLAS Standards 

•	 Organization-wide database of race, ethnicity, sex, language, and disability status of consumers 

•	 Analytic plan for ongoing assessment of the impact of CLAS on health equity and outcomes 

and to inform service delivery (e.g., service utilization by race/ethnicity). 

72 
 

 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

Table 6 illustrates an example of how to align the elements of a logic model using the points 

above, making it easier to develop or choose metrics and evaluation questions. 

TABLE 6. ALIGNING THE LOGIC MODEL 

CONTEXT, 

ANTECEDENTS, 

AND INPUTS 

PROPOSED CHANGES 

AND STRATEGIES FOR 

IMPLEMENTATION OUTPUTS 

OUTCOMES AND IMPACTS 

SHORT TERM LONGER TERM 

Engagement, 

Continuous 

Improvement, 

and 

Accountability 

(Standards 

9–15) 

Organizational 

leadership 

emphasizes 

their mission to 

implement the 

National CLAS 

Standards 

Having a written 

policy that 

reinforces the 

organization’s 

commitment to 

assessing the 

progress of CLASrelated activities 

Organization 

creates a 

structure for 

measuring 

CLAS implementation 

National CLAS 

Standards are 

implemented, 

evaluated, and 

a new process 

for refining the 

approach to 

implementing 

CLAS is 

developed 

73 
 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

HOW COULD I SHAPE MY EVALUATION TO ASSESS 

IMPLEMENTATION AND EFFECTIVENESS OF THESE STANDARDS? 

In Chapter 2, we discussed set of overarching evaluation questions about the outcomes resulting from implementation of the National CLAS Standards following the logic model format 

description. As you read through the questions again, think to yourself about what these 

questions mean in the context of Standards 9–15, which relate to engagement, continuous 

improvement, and accountability. You should be able to observe changes within your organization and among the consumers you serve. 

In both the short and long term, you should observe changes in how your organization 

develops its approach to implementation of the National CLAS Standards overall. In the short 

term, for example, think about how integrating CLAS goals into your operations would help 

consumers better access and navigate health care services. Or think about how conducting 

assessments and quality improvement activities would help to improve access to high-quality 

language services for ethnic and minority populations. In the long term, has integrating CLAS 

into your policies and procedures led to a cultural shift in your organization toward greater 

workforce buy-in of culturally and linguistically appropriate care and services? And how has 

implementing assessments improved satisfaction among individuals seeking your services over 

time? These pathways may help you to think about important process, implementation, and 

outcome measures you wish to capture in your evaluation. 

In Table 7, we present some example metrics you can use to assess your progress toward 

implementing practices that align with Standards 9–15, as well as the outcomes of those 

processes for your organization and those you serve. This is not a comprehensive list, but it will 

74 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 


ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

help you get started and may complement metrics you already collect. Note that since Standard 

10 relates to conducting assessments for CLAS-related activities, many of the metrics and ways of 

assessing the other National CLAS Standards are relevant to assessing practices that align with 

Standard 10. 

TABLE 7. METRICS AND WAYS OF ASSESSING STANDARDS 9–15 

EXAMPLE METRIC	 DESCRIPTION 

CAHPS Cultural 

Competence Item 

Set: linguistic 

competency 

(access to 

language services), 

experiences of 

discrimination 

because of 

race/ethnicity, 

insurance, or 

language measures 

CAHPS Cultural Competence items are a set of supplemental items for the CAHPS Clinician/ 

Group Survey that ask consumers about their experiences with the cultural competence 

of an organization that provided them services. CAHPS Cultural Competence items were 

designed for medical practices and clinics, but questions could be applied to diverse health 

care and public health settings. Scores are calculated for five item sets. 

The linguistic competency (access to language services) and experiences of discrimination 

because of race/ethnicity, insurance, or language items are the most relevant for 

Standard 9 and assess such things as 

•	 patients’ preferred language 

•	 availability and promotion of language services 

•	 patients’ experiences being treated unfairly at this provider’s office because of their 

race or ethnicity. 

75 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

EXAMPLE METRIC	 DESCRIPTION 

C-CAT, leadership 

commitment, 

workforce 

development, 

performance 

evaluation, 

data collection, 

community 

engagement, 

and cross-cultural 

communication 

domains 

The C-CAT provides assessments of consumers, staff, and organizational leadership to 

comprehensively measure the implementation and outcomes of providing language 

services. C-CAT has been validated in diverse health care settings nationwide. C-CAT scores 

are calculated on nine domains. 

The leadership commitment, workforce development, performance evaluation, data 

collection, community engagement, and cross-cultural communication domains are 

•	 policies that make effective communication a high priority 

•	 evaluation of achievement of effective communication goals 

•	 practices for assessing each patient’s cultural beliefs, barriers to communication, and 

the like 

•	 use of feedback from patients to improve communication 

•	 how well organizations track language service usage and satisfaction 

•	 performance evaluation system’s capacity to assess staff cross-cultural
 

communication skills
 

•	 whether patients understand documents, educational materials, and surveys 

•	 whether patients were asked about their race, ethnicity, and preferred language 

(patient perspective) 

•	 how often staff collect race/ethnicity information from patients (staff perspective) 

•	 work with local community and advocacy groups to collect information about new 

and emerging populations 

•	 who (individual or committee) is charged with outreach and maintaining ties to 

community partners 

•	 consumer awareness of who to call with feedback/complaints. 

76 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

EXAMPLE METRIC	 DESCRIPTION 

Cultural 

Competency 

Implementation 

Measure, 

commitment to 

serving a diverse 

population, 

dedicated staff and 

resources, strategic 

planning, reward 

systems, quality 

improvement, 

assessment 

of patient 

experiences with 

care, collection of 

patient cultural 

competency– 

related 

information, 

community 

outreach 

subdomains 

The Cultural Competency Implementation Measure is an organizational survey designed 

to assist HCOs in identifying the degree to which they are providing culturally competent 

care and addressing the needs of diverse populations. The Cultural Competency 

Implementation Measure was designed for use in diverse health care settings. Scores are 

calculated for 12 subdomains. 

Several subdomains are relevant to this group of Standards (e.g., commitment to serving 

a diverse population, dedicated staff and resources, strategic planning, reward systems, 

quality improvement, assessment of patient experiences with care, collection of patient 

cultural competency–related information, and community outreach) and include items 

assessing 

•	 the organization’s mission, vision, and goals for commitment to cultural competency 

•	 documentation of fiscal support for culturally competent policies and practices 

•	 involvement of staff and community members in the process of developing and
 

refining goals, plans, and policies for culturally competent services
 

•	 whether an organizational self-assessment has been completed to inform goals, 

plans, and policies 

•	 identification of performance measures to collect and use to support more culturally 

competent care 

•	 use of surveys to collect information on patient experiences with care 

•	 policies and procedures to ensure that race/ethnicity data is not used for
 

discriminatory purposes
 

•	 development, maintenance, and improvement of processes for integrating patient 

data into information systems 

•	 whether data on community needs have been gathered to inform the development 

and refinement of goals, plans, and policies 

•	 existence of collaborative relationships with community organizations. 

77 
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

CHAPTER 3: TIPS FOR EVALUATING THE NATIONAL CLAS STANDARDS 

ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

EXAMPLE METRIC DESCRIPTION 

Screening for 

preferred spoken 

language for 

health care 

measure 

The screening for preferred spoken language for health care measure is used to assess 

the percentage of patient visits and admissions where the preferred spoken language for 

health care is screened and recorded. It relies on administrative claims, electronic health 

records, or other records of consumer visits. The measure was designed for use by hospitals 

and outpatient clinics, but could be applied across health care settings where patient 

records are kept. 

This measure is calculated by determining the number of hospital admissions, visits to the 

emergency department, and outpatient visits where preferred spoken language for health 

care is screened and recorded and dividing that number by the total number of hospital 

admissions, visits to the emergency department, and outpatient visits. 

Patients receiving 

language services 

supported by 

qualified language 

services providers 

measure 

This measure is used to assess the percentage of LEP patients receiving both initial 

assessment and discharge instructions supported by assessed and trained interpreters 

or from bilingual providers and bilingual workers/employees assessed for language 

proficiency. It relies on administrative claims, electronic health records, or other records 

of consumer visits. This measure was designed for use in medical practices and clinics, but 

questions could be applied to diverse health care and public health settings. 

This measure is calculated by determining the number of LEP patients with documentation 

that they received the initial assessment and discharge instructions and were supported 

by trained and assessed interpreters and dividing that number by the total number of 

patients that stated a preference to receive their spoken health care in a language other 

than English. 

78 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Chapter 4 

Evaluation Resources
 

Earlier chapters of this toolkit provide helpful tips, insights, and examples related to the design and planning of an evaluation of the National CLAS Standards within a health setting. This chapter is designed to 

provide a guide to additional setting-specific information and resources that are useful for evaluating the 

National CLAS Standards. We provide a guide to the setting-specific appendixes which each discuss additional information on the importance of the National CLAS Standards to that setting, as well as information 

on the development of a setting-specific logic model. In the appendixes, we also provide tables of measures 

specific to each setting that may be used in an evaluation. We provide the measure name, description of 

the measure, general area of focus (e.g., health literacy, cultural competency), specific wording of relevant items, and the source and reference of the measure. We also include measures that are considered 

cross-cutting, meaning measures and resources that are broadly applicable to all settings. 

Appendix A. Ambulatory care setting 

• Logic model and relevance of the National CLAS Standards to ambulatory care 

• Measures tables 

Appendix B. Behavioral health setting 

• Logic model and relevance of the National CLAS Standards to behavioral health 

• Measures tables 

Appendix C. Hospital setting 

• Logic model and relevance of the National CLAS Standards to hospitals 

• Measures tables 

Appendix D. Public health setting 

• Logic model and relevance of the National CLAS Standards to public health 

• Measures tables 

Appendix E. Cross-cutting measures 

79 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Appendix A 

Ambulatory Care Setting
 

Ambulatory (i.e., walk-in) or outpatient care settings are where the vast majority of health care 

is received in the United States. It is estimated that there are over 928 million outpatient visits to 

physician offices each year and more than 125 million outpatient visits to hospitals (Centers for 

Disease Control and Prevention [CDC], 2016b). Ambulatory Care Settings (ACSs) include doctors’ 

offices, outpatient clinics, community clinics, Federally Qualified Health Centers (FQHCs), rehabilitation centers, urgent care, emergency rooms, and ambulatory surgery clinics, among other 

settings. Depending on the type of ACS, they can range in size from a few clinician providers and 

support staff serving several hundred patients to several hundred providers and support staff 

serving tens of thousands of patients. ACSs can be freestanding or part of a larger medical facility, such as a medical center. Each ACS may operate independently with its own management 

(e.g., an FQHC), as part of a larger organization (e.g., a primary care division within a hospital 

or a large multispecialty group), or as one of a network of organizations (e.g., a large physician 

provider group made up of private practices throughout a community, but with shared management services and oversight). 

Despite these differences, health care providers and organizational leaders within and across 

all types of ACSs share challenges and responsibilities with respect to recognizing and ensuring 

that cultural and linguistic issues are adequately addressed. While cultural and linguistic needs 

and concerns are often thought of as mainly relevant to community clinics or FQHCs that 

serve predominantly minority and/or low-income populations, the reality is that with growing 

numbers of insured individuals and demographic changes in the United States, these issues are 

becoming increasingly relevant in almost all types of ACSs. 

In this report, we focus on ACSs that are sufficient in size and resources to have one or more 

management staff focused on quality improvement (QI) and/or cultural or language activities, 

80 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 


as in the case of the other types of HCOs discussed. Awareness of cultural and linguistic needs 

and guidelines is also salient to providers and staff in smaller ACSs (e.g., cultural competence 

training is still essential for clinicians and staff), but formally implementing all of the National 

CLAS Standards may not be feasible in these settings. Examples of ACSs where OMH’s National 

CLAS Standards are directly applicable include FQHCs, urgent care centers or outpatient 

divisions in medical centers, large physician groups (e.g., independent physician associations, 

independent practice associations), and multispecialty clinics. The National CLAS Standards are 

also applicable to managed health plans and a variety of different types of emerging managed 

care organizations, such as accountable care organizations (ACOs). 

While leadership and staff in some types of ACSs may have extensive experience and wellestablished infrastructure to provide culturally and linguistically appropriate services (e.g., FQHCs 

or some health plans), such resources may be more variable and less developed throughout the 

HCOs in other types of ACSs. Consequently, in many ACSs, the risk of cultural misunderstandings 

or language barriers remains high for growing subgroups of patients (Institute of Medicine, 

2004). While failure to provide culturally and linguistically appropriate services is likely to result 

in lower satisfaction for the patient and provider, in many cases and settings, this can have 

more dire effects. For example, routine miscommunications and cultural misunderstandings in a 

private, multispecialty clinic between providers and patients with significant cardiac risk factors 

could potentially reduce the likelihood that patients will properly use or adhere to prescribed 

medications and thus could increase largely preventable heart attacks or strokes in the patients 

served. 

An additional layer of complexity in the United States with respect to understanding and 

81 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 


addressing the needs of diverse populations served in ambulatory settings relates to the role of 

managed care plans operated by large health insurers and health reforms intended to promote 

more value and better outcomes for health care beneficiaries. Managed care plans receive 

funds from payers (employers, government, and individuals) to help ensure that enrolled 

members receive quality care at reasonable costs. The managed care plans, in turn, contract 

with providers and HCOs and pay them a portion of the funds to deliver the actual health 

care. Increasingly, the focus of payers and, consequently, health insurers, is on value-based 

payments. Value-based payment systems are intended to reward health care providers and 

delivery systems that can show higher-quality scores on the measures of care delivered to their 

patients and on the health outcomes experienced by those patients. (To receive full payments 

or bonuses, contracted providers and the delivery system also generally need to keep average 

costs of the care for patients they serve to a relatively low level.) 

The growing emphasis on value-based care is increasing the salience of addressing diverse 

cultural and linguistic needs for ACSs. For example, the fact that payments to providers in ACSs 

increasingly depend on the outcomes of their patient population is compelling ACS leaders 

to better understand the populations they serve and address disparities between patient 

subgroups when found. Providing further motivation for ACS leaders to begin routinely 

examining whether patterns of care and outcomes significantly differ for patients from racial/ 

ethnic minority groups or non-English speakers, state and possibly federal entities are requiring 

health insurers (who pay providers) to begin tracking and acting on identified racial/ethnic or 

linguistic disparities in care and to implement other recommended National CLAS Standards 

and practices. 

82 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 

LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 

AMBULATORY CARE SETTING 

Figure A.1 provides a detailed logic model of the specific inputs, activities, outputs, and outcomes for the implementation of the National CLAS Standards within an ACS. Given the importance of the broader context, external resources, and partnerships in shaping an ACS’s readiness 

for adopting the Standards, we include them in the context, antecedents, and inputs section 

and note that any changes should be made in partnership with the community and other stakeholders. 

CONTEXT, ANTECEDENTS, AND INPUTS 

Linkages with the Community and Other Stakeholders 

Of all ACSs, FQHCs tend to have more ties to local community partners, such as food pantries, 

shelters, churches, and hospitals, than other provider groups that tend to care for more private 

or commercially insured or Medicare patients. As a result, linkages with stakeholders and the 

broader community vary significantly, depending on the population served and the broader 

needs of the patient population. However, in a growing number of regions, large clinics and 

provider groups are beginning to work together through multistakeholder collaboratives and 

initiatives to improve care and outcomes of certain conditions. For example, as part of a project 

sponsored by CDC, selected provider groups in southeast San Diego are beginning to work in 

concert with local faith-based organizations to help reduce cardiac risks among people living in 

that region (“Be There San Diego,” undated). In early 2016, the Centers for Medicare & Medicaid Services (CMS) introduced the Accountable Health Communities Model (AHCM) to tackle the 

83 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 

LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 

AMBULATORY CARE SETTING 

high prevalence of unmet health-related social needs that contribute to poor health and to address the current gap between clinical care and community services (CMS, 2016a). In the AHCM, 

universal, comprehensive screening in the areas of housing instability and housing quality, food 

insecurity, utility needs, interpersonal violence, and transportation needs will be conducted in 

the ACSs, and affected individuals will be linked to social services (CMS, 2016a; Alley et al., 2016). 

Questions about whether and how these models most effectively address health inequities and 

reduce health disparities will be answered over time, but all point to a need to consider how ambulatory care centers work with their partner and contracted organizations with respect to the 

National CLAS Standards, because this may influence their overall performance. Such partners 

should be involved at all steps of the process (e.g., assessment, design, implementation, evaluation). 

84 
RAND RR2157-3.1

APPENDIX A: AMBULATORY CARE SETTING 


LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE AMBULATORY CARE SETTING
 

FIGURE A.1. LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN THE AMBULATORY CARE SETTING
 

Context, Antecedents, and Inputs 

Community/stakeholders 

• Hospitals 

• Other ambulatory care 

• Public health 

• Insurers 

• Community health workers/promotores de 

salud 

• Community organizations 

o Social service 

Environmental/policy context 

• Affordable Care Act (ACA) 

• Accreditation (e.g., Joint Commission 

standards) 

• Value-based care and payment models 

• Triple Aim: cost, quality, experience 

• Title VI of 1964 Civil Rights Act 

• Consumer informatics 

Community/catchment area 

• Ethnicity, culture, and language 

• Urban or rural 

• Engagement with ambulatory care 

o Boards, planning committees, and input 

• Unmet needs 

Ambulatory care context/resources 

• Size and structure 

• Part of network 

• Organizational policies, priorities 

• Resources 

o Financial 

o Staff time, skills, and capacities 

o Interpretation and translation services 

o Physical space, equipment 

• Needs assessment 

o Gaps in activities, structures, and policies 

o Gaps in implementation factors 

Organization Organization 

Provision of quality care and services that are 

responsive to diverse cultural health beliefs 

Continued improvement in provision of 

high-quality services related to National CLAS 

Standards 

Better patient outcomes, improved safety, 

higher-quality care, higher patient satisfaction 

Provision of quality care and services that are 

responsive to preferred languages, health 

literacy, and other communication needs 

Individuals have access to high-quality language 

services. 

Individuals are empowered to become active 

participants in their health. 

Increased use of appropriate care services with 

regular follow-up and continuity of care 

Improved satisfaction among individuals seeking 

ambulatory care services 

Reduced disparities 

Improved health and well-being 

Increased trust in and engagement with the 

provider and ambulatory care setting more 

broadly 

Individuals are better able to access and 

navigate ambulatory care setting to receive 

primary, preventive, and acute care services. 

Individuals are better able to understand their 

treatment options and make informed care 

decisions. 

Individuals understand and can navigate referral 

process to see specialists. 

Individuals have greater adherence to 

medication and treatment protocols and 

follow-up visits. 

Proposed Changes and Strategies to Outputs Implement Those Changes

National CLAS Standards 

Changes to 

organizational 

policies 

Changes to 

processes 

and 

practices 

Changes to 

structure, 

staffing, and 

resources 

Diverse viewpoints from within and outside of 

the organization are incorporated in 

organizational planning. 

National CLAS Standards are built into 

organization’s mission, goals, and policies, and 

are central to the organization’s functions. 

Increased knowledge and skills for all staff 

related to delivering culturally and linguistically 

appropriate care at all levels of the organization 

Organization has ethnically diverse providers and 

staff at all levels, including boards and senior 

administration 

Standards of practice implemented around clear 

communication, access to language services, and 

notification of rights 

Written information (e.g., instructions, consent 

forms) is developed and provided in multiple 

languages. 

Transparency within and outside organization is 

attained with respect to implementation of the 

National CLAS Standards. 

Improvement in physical layout, signage, ease of 

access, and navigation 

Dedicated resources and accountability to 

support/sustain initiatives and efforts related to 

the National CLAS Standards, including language 

services 

Improved collection of, access to, geographic 

mapping of, and dissemination of accurate 

population data, particularly for ethnic and 

minority populations 

An understanding of the assets and needs of the 

organization and service area is achieved. 

Continuous improvement 

Outcomes and Impacts 

Longer Term 

Individual/Client 

Data on race, ethnicity, sex, disability status, and 

language are used to monitor and improve 

service delivery within ambulatory care setting. 

Improved two-way communication and 

feedback mechanisms between individuals and 

providers 

Racial/ethnic/linguistic concordance between 

providers and patients 

Shorter Term 

Individual/Client 

Increased equity in access to high-quality 

services and a reduction in health disparities 

Increased trust and engagement between 

communities and ambulatory care setting 

Organizational culture shifts to provide ongoing 

and visible support for National CLAS Standards 

85 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 

LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 

AMBULATORY CARE SETTING 

Environmental and Policy Context 

Implementation of the National CLAS Standards within an organization is affected by a number 

of factors external to the organization itself. These factors include, for example, the federal, 

state, tribal, and local regulatory environment; accreditation mandates; policies; and standards 

of practice. In many cases, these factors influence how care is delivered and monitored and may 

impact whether and how organizations choose to adopt the Standards. 

Health care, especially in ACSs, has been undergoing unprecedented changes during the 

past decade, and it is likely that some aspects of care in some ACSs will be unrecognizable five 

years from now. These changes are being driven partly by health care reforms, such as the ACA, 

as well as by the convergence of other factors, such as breakthroughs in mobile and wireless 

communications and biomedical advances. While these sorts of changes are manifesting 

in different ways, some of the most notable shifts relevant to the implementation of the 

Standards include 

•	 Increasing emphasis on value-based care. Requirements have been increasing for 

reporting ambulatory care quality measures, including process and intermediate 

outcomes measures, e.g., Health Indicators Warehouse’s Healthcare Effectiveness Data 

and Information Set (HEDIS) (Health Indicators Warehouse, undated) and the Agency 

for Healthcare Research and Quality’s (AHRQ’s) Ambulatory Consumer Assessment of 

Healthcare Providers and Systems (AHRQ, undated). This increase is partly driven by 

newer financing and care delivery models, which tie payments or other incentives to 

positive clinical outcomes among the ACS’s patient population. Since outcomes tend to 

be worse in minority and/or lower–socioeconomic status (SES) populations where cultural 

86 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 


LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 

AMBULATORY CARE SETTING 

and linguistic needs are thought to play a prominent role, ACS leaders may be motivated 

to adopt and apply the National CLAS Standards. However, widespread uptake and full 

implementation of the Standards will likely take time in many ambulatory settings and 

particularly in smaller sites because of competing demands, bandwidth issues, and a focus 

primarily on improving quality scores for the overall population. 

• Improving health care and consumer informatics. Many, although not all, ACSs have 

undergone a transformation in recent years with respect to improvements in their 

electronic medical records (EMRs) and in their access to easy-to-use data analytics tools 

to support QI efforts. At the same time, consumers’ access to interactive web tools with 

provider or regional-level quality report cards has been proliferating (CMS, 2016b). While 

the norm has been to only show quality scores for the overall patient populations that 

ambulatory providers serve, expectations for reporting quality scores for major racial/ 

ethnic and linguistic groups (when there are enough patients to ensure confidentiality) 

will likely increase as race/ethnicity and language data become more readily available in 

non-FQHC ambulatory sites. 

• Leveraging meaningful use of health information technology (HIT) to reduce health 

disparities. The Health Information Technology for Economic and Clinical Health (HITECH) 

Act was intended to promote the adoption and meaningful use of HIT (HHS, undated[a]). 

One of the Act’s stated goals is to address health disparities. The Electronic Health Record 

Incentive Program, commonly referred to as “Meaningful Use,” provides a relatively 

untapped opportunity to help ACSs collect more-granular data on patients’ race, ethnicity, 

language, and other relevant characteristics. Given the increasing use of patient portals 

and other HIT that enables patients to access health information, decision support 

tools, test results, and correspondence with providers, some are calling for an expansion 

of Meaningful Use criteria to ensure that such technologies are being developed and 

implemented with the National CLAS Standards in mind (Consumer Partnership for 

eHealth, 2013). 

87 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 

LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 

AMBULATORY CARE SETTING 

•	 Health care reforms and demographic shifts. As alluded to previously, not only is the 

overall U.S. population quickly becoming more ethnically, culturally, and linguistically 

diverse in most geographic regions, but Medicaid expansion and the establishment of 

commercial insurance health plan exchanges in many states are further changing the 

typical mix and flow of patients to different types of ACSs. 

Finally, there are a number of other influences relevant to the provision of culturally and 

linguistically appropriate services more broadly. For example, under Title VI of the Civil Rights 

Act of 1964 (Chen, Youdelman, and Brooks, 2007), organizations receiving federal funds must 

take reasonable steps to provide meaningful access to their programs for individuals with LEP 

(U.S. Department of Justice, 2000). Furthermore, several states have recognized the importance 

of cultural and linguistic competency by legislating competency training in health care (HHS 

OMH, 2013). Accrediting bodies—such as The Joint Commission and the National Committee for 

Quality Assurance—have also established accreditation standards that target the improvement 

of communication, cultural competency, and patient-centered care and the provision of 

language assistance services (Briefer French et al., 2008; Wilson-Stronks and Galvez, 2007; HHS 

OMH, 2013). 

The above examples of external influences and contexts may impact whether and how an ACS 

will adopt the National CLAS Standards and how easy or difficult such implementation may be. 

Ambulatory Care Context, Resources, Community, and Catchment Area 

Inputs and antecedents relevant to implementing the National CLAS Standards can vary considerably depending on the type of ACS (e.g., FQHC, small office, large practice) and on whether 

the ambulatory care location is part of a larger network. Practice size and group organization 

88 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 

LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 


AMBULATORY CARE SETTING
 

play an increasingly important role in many ACSs and can be a major factor in the uptake and 

implementation of the National CLAS Standards. For example, while smaller clinics or provider 

groups are much less likely to have the capacity or bandwidth to address diverse cultural and 

linguistic needs, larger clinics and provider groups may have staff members specifically tasked 

with leading or managing aspects of implementing and assessing the Standards within the clinic 

or network providers. However, one advantage of smaller clinics is that they may be nimbler 

and can come to know and respond to their patient population’s needs better than some of the 

bigger, higher-volume clinics. Other inputs and antecedents—such as the ACS’s strategic goals, 

policies, staff, resources, and physical space—may also play a role in the center’s ability to adopt 

and implement the National CLAS Standards. For example, a lack of sufficient space and staff is 

often cited as a barrier to other types of QI efforts and may affect an organization’s ability to 

implement the Standards. 

Also relevant is the organization’s capacity to absorb new knowledge and its receptivity 

for change, which may be driven, for example, by a gap analysis or a needs assessment. This 

assessment should include activities, structures, or policies that should be in place to support 

equitable care as well as implementation factors that could aid or hinder the adoption of the 

National CLAS Standards. The use of gap analyses varies in ACSs, but it generally falls under the 

rubric of CQI and may be completed as part of ongoing accreditation requirements. 

NATIONAL CLAS STANDARDS 

In this logic model, the National CLAS Standards are placed between the antecedents and inputs 

and the activities an organization adopts. Here, the National CLAS Standards are viewed as a 

89 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 

LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 


AMBULATORY CARE SETTING
 

perspective or lens through which such context and antecedents are interpreted and which help 

to shape the activities the organization chooses to implement to address gaps in culturally and 

linguistically appropriate care. 

PROPOSED CHANGES AND STRATEGIES DEVELOPED TO IMPLEMENT 

THOSE CHANGES 

Once an organization has decided to address identified gaps with respect to the National CLAS 

Standards, it must design relevant activities and approaches to close the gaps and develop implementation strategies to enhance the adoption and sustainability of those changes (Powell et 

al., 2015). Organizations may adopt the Standards altogether or in a staged approach, depending on the antecedents and inputs, the organization’s readiness for implementing the National 

CLAS Standards, and the environmental and policy context. Given the wide range of potential 

approaches and activities an ACS may choose to develop or adopt, the logic model does not list 

specific activities; rather, it notes that changes are likely to occur in three nested areas of focus: 

(1) organizational policies; (2) structure, staffing, and resources; and (3) processes and practices. 

Changes to organizational policies include making the National CLAS Standards central to the 

organization’s functions and building them into the organization’s mission, goals, and policies. 

Engaging diverse viewpoints both from inside and outside the ACS into planning is particularly 

important. Building this orientation to the Standards into the organization’s approach is 

especially important when the ACS seeks to implement the Standards across multiple providers 

and office locations. 

Changes to an ACS’s organizational structure, staffing, and resources require that the ACS 

90 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 


LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 

AMBULATORY CARE SETTING 

leaders have identified the necessary skill set for their staff to address the diverse cultural and 

linguistic needs of their patient population and require that they have the capacity to train staff 

when necessary. The organization should be focused both on diversifying its frontline staff and 

on having an ethnically diverse staff at all levels, including boards and senior administration. 

Changes to organizational structure include making improvements in the ease of access to its 

physical space and to the accessibility of information it provides to consumers through signage. 

In addition, the ACS should have dedicated resources to support and sustain the implementation 

of the Standards, including the availability of language services and a process for holding itself 

accountable for these improvements. 

Changes to processes and practices encompass all of the unique functions of ambulatory care, 

including the provision of health care and services, diagnostic testing, treatment and follow-up, 

and referral to specialty providers. Changes would also involve a number of other relevant tasks, 

including health education, obtaining consent, discussing the use or sharing of medical data, 

and health insurance and billing. 

The design and development of activities to address those gaps, and the development of 

an implementation strategy will benefit from close collaboration with, and input from, the 

community and other stakeholders that stand to benefit from such changes. Because of the 

heterogeneity of ACSs, the results of these gap analyses will be very different. Many ACSs, 

such as FQHCs, are uniquely positioned to draw out these lessons from stakeholders because 

of their long-standing partnerships, but not all ACSs are. Building a focus on the National CLAS 

Standards into organizational policy, practice, staffing, and resources is critical to ensuring 

that every ACS, no matter the context, takes appropriate steps to ensure that its services are 

accessible to all members of the community. 

91 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 


LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 

AMBULATORY CARE SETTING 

OUTPUTS 

The activities and changes implemented within the organization should result in immediate outputs that move the organization toward providing culturally and linguistically appropriate care 

and services. Such outputs may include 

•	 incorporating diverse viewpoints from inside and outside the ACS into planning and 


implementation of policies, programs, and services, and building the National CLAS 


Standards into the ACS’s mission, goals, and policies
 

•	 implementing standards of practice around clear communication, access to language 


services, and notification of rights
 

•	 increasing staff knowledge and skills related to delivering culturally and linguistically 


appropriate care at all levels of the organization
 

•	 incorporating ethnically diverse public health practitioners and staff at all levels of the 

organization 

•	 improving the physical layout, signage, ease of access, and navigation 

•	 improving the collection of, access to, geographic mapping of, and dissemination of 


accurate population data, particularly for ethnic and minority populations
 

•	 ensuring that resources and accountability to support and sustain initiatives and efforts 

related to meeting the National CLAS Standards are available. 

The specific outputs expected will be determined by which Standards have been adopted, 

which organizational changes have been made, and by which activities have been implemented 

as a result. 

92 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 

LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 


AMBULATORY CARE SETTING
 

OUTCOMES 

Collectively and over time, outputs from the ACS may contribute to changes in outcomes for 

individuals using ambulatory care services, as well as for the ACS organization overall. Examples 

of potential outcomes are listed below. 

• For the organization 

– Short term (1–2 years) 

> the provision of effective, equitable, understandable, respectful, and quality care 

and services that are responsive to diverse cultural health beliefs and practices, 

preferred languages, health literacy, and other communication needs 

> data on race, ethnicity, sex, disability status, and language are used to monitor 

and improve service delivery within the ACS 

> improved two-way communication and feedback mechanisms between 

individuals and providers 

> enhanced or improved racial/ethnic and linguistic concordance among providers, 

ambulatory care staff, and patients 

– Longer term (3 or more years) 

> continued improvement in the provision of high-quality services related to the 

National CLAS Standards 

> better patient outcomes, improved safety, higher-quality care, and higher patient 

satisfaction 

> organizational culture shifts to provide ongoing and visible support for the 

93 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 

LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 


AMBULATORY CARE SETTING
 

National CLAS Standards within the ACS 

> increased equity in access to high-quality services and a reduction in health 

disparities 

> increased trust and engagement between communities and ACSs. 

• For the individuals seeking care 

– Short term (1–2 years) 

> individuals have access to high-quality language services 

> individuals are better able to access and navigate ambulatory care services to 

receive primary, preventive, and acute care services 

> individuals are better able to understand their treatment options and make 

informed care decisions 

> individuals understand and can navigate the referral process to see specialists 

> individuals have greater adherence to medication and treatment protocols and 

follow-up visits 

– Longer term (3 or more years) 

> individuals are empowered to become active participants in their health 

> improved satisfaction among individuals seeking ambulatory care services 

> increased trust in and engagement with the provider and ACS more broadly 

> increased use of appropriate care services with regular follow-up and continuity 

of care
 

> disparities are reduced
 

> improved health and well-being.
 

94 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 

LOGIC MODEL FOR IMPLEMENTING THE NATIONAL CLAS STANDARDS WITHIN THE 

AMBULATORY CARE SETTING 

QUALITY IMPROVEMENT 

The logic model depicts adoption and implementation of the National CLAS Standards as a 

continual process, requiring a QI loop where outputs and outcomes inform the development 

of future ACS actions, policies, or programs to better align with the National CLAS Standards. 

Standard QI efforts, however, are broadly targeted to the general patient population and may 

maintain or increase health disparities (Green et al., 2010). Culturally competent QI tailors care 

to address the specific language and culture barriers, which both helps to reduce disparities 

and can improve care for everyone (Green et al., 2010). It is important that QI improvements be 

viewed specifically through a culturally competent lens when assessing the impact of the implementation of the National CLAS Standards and informing next steps. 

95 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX A: AMBULATORY CARE SETTING 


AMBULATORY CARE MEASURES 


In developing the process and outcomes/impact measures described in Chapter Seven of the main report 

(Davis et al., forthcoming), we identified measures relevant to the ambulatory care setting. In Table A.1, 

we list examples of ambulatory care measures identified along with a brief description, area of focus, 

source, relevant notes, and the reference for each measure. In addition, we include examples of disparity-sensitive measures that an ambulatory care organization might wish to consider to help it assess how 

well it is doing in addressing identified disparities in outcomes. Table A.2 provides additional detail for 

each measure and summarizes the relevant items that compose each measure. 

96 
APPENDIX A: AMBULATORY CARE SETTING 


AMBULATORY CARE MEASURES 

TABLE A.1. LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN THE 

AMBULATORY CARE SETTING 

MEASURE DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE

CAHPS 

Cultural 

Competence 

Set 

CAHPS surveys ask consumers and patients to report on and evaluate 

their experiences with health care. The CAHPS Cultural Competence 

Item Set, a supplement to the CAHPS Survey, is designed to capture the 

patient’s perspective on the cultural competence of health care providers. The Cultural Competence Item Set covers the following topics: 

patient-provider communication; complementary and alternative medicine; experiences of discrimination because of race/ethnicity, insurance, or 

language; experiences leading to trust or distrust, including level of trust, 

caring, and truth-telling; and linguistic competency (access to language 

services). 

In Weech-Maldonado et al. (2012b), measures are grouped into 

eight composites: doctor communication (positive behaviors), doctor 

communication (negative behaviors), trust; access to interpreter services; 

doctor communication (health promotion); doctor communication 

(alternative medicine); shared decisionmaking; equitable treatment 

Cultural 

competency 

CAHPS 

Cultural 

Competence Item 

Set 

See Table 

C.2 for list of 

measures. 

AHRQ, 2012 

WeechMaldonado 

et al., 2012b 

Clinician 

and Group 

Consumer 

Assessment 

of Healthcare Provider 

and Systems 

(CG-CAHPS) 

CAHPS surveys ask consumers and patients to report on and evaluate 

their experiences with health care. The CG-CAHPS assesses patients’ 

experiences with health care providers and staff in doctors’ offices. 

The CG-CAHPS produces the following measures of patient experience: 

getting timely appointments, care, and information; how well providers 

communicate with patients; providers’ use of information to coordinate 

patient care; helpful, courteous, and respectful office staff; and patients’ 

rating of the provider. 

Patient 

experience 

CG-CAHPS See Table 

C.2 for list of 

measures. 

AHRQ, 

2013b 

97 
APPENDIX A: AMBULATORY CARE SETTING 


AMBULATORY CARE MEASURES 


MEASURE DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

Disparity-sensitive measures or CLAS-salient measures 

Controlling 

high blood 

pressure 

The percentage of patients ages 18 to 85 who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled 

(< 140/90) during the measurement year. 

Prevention 

and 

treatment, 

effective 

clinical care 

National 

Quality 

Forum 

(NQF) #18 

(measure 

steward: 

NCQA) 

BP < 150/90 

in patients 

ages 60 and 

older without 

diabetes 

considered 

controlled in 

HEDIS 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: 

“18”) 

NQF, 2012g 

Diabetes: 

hemoglobin 

A1c poor 

control 

The percentage of patients ages 18 to 75 with diabetes (type 1 and 

type 2) whose most recent HbA1c level during the measurement year was 

greater than 9.0% (poor control) or was missing a result, or if an HbA1c 

test was not done during the measurement year. 

Effective 

communication and 

care coordination 

NQF #59, 

#575 

(measure 

steward: 

NCQA) 

HbA1c < 8% 

also valid 

measure given 

improvements 

in control 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: “59” 

or “575”) 

NQF, 2012g 

98 
APPENDIX A: AMBULATORY CARE SETTING 


AMBULATORY CARE MEASURES 


MEASURE DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

Uncontrolled 

diabetes 

admission 

rate 

Admissions for a principal diagnosis of diabetes without mention of 

short-term (ketoacidosis, hyperosmolarity, or coma) or long-term (renal, 

eye, neurological, circulatory, or other unspecified) complications per 

100,000 people ages 18 and older. Excludes obstetric admissions and 

transfers from other institutions. 

Patient 

safety, 

primary 

prevention 

NQF #638 

(measure 

steward: 

AHRQ) 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: 

“638”) 

NQF, 2012g 

Diabetes 

short-term 

complications 

admission 

rate 

Admissions for a principal diagnosis of diabetes with short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 people 

ages 18 and older. Excludes obstetric admissions and transfers from other 

institutions. 

Patient 

safety, 

primary 

prevention 

NQF #272 

(measure 

steward: 

AHRQ) 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: 

“272”) 

NQF, 2012g 

99 
APPENDIX A: AMBULATORY CARE SETTING 


AMBULATORY CARE MEASURES 

TABLE A.2. AMBULATORY CARE MEASURES: ADDITIONAL DETAILS 

MEASURE ITEMS 

CAHPS Cultural 

Competence Set 

CAHPS surveys ask consumers and patients to report on and evaluate their experiences with health care. The CAHPS 

Cultural Competence Item Set, a supplement to the CAHPS Survey, is designed to capture the patient’s perspective on 

the cultural competence of health care providers. The Cultural Competence Item Set covers the following topics: patientprovider communication; complementary and alternative medicine; experiences of discrimination because of race/ethnicity, 

insurance, or language; experiences leading to trust or distrust, including level of trust, caring, and truth-telling; linguistic 

competency (access to language services). 

In Weech-Maldonado et al. (2012b), measures are grouped into eight composites: doctor communication (positive 

behaviors); doctor communication (negative behaviors); trust; access to interpreter services; doctor communication (health 

promotion); doctor communication (alternative medicine); shared decisionmaking; equitable treatment. 

Doctor 

communication 

(positive behaviors) 

In the last 12 months, how often did this doctor explain things in a way that was easy to understand? 

In the last 12 months, how often did this doctor listen carefully to you? 

In the last 12 months, how often did this doctor spend enough time with you? 

In the last 12 months, how often did this doctor show respect for what you had to say? 

In the last 12 months, how often did this doctor give you easy-to-understand instructions about taking care of these health 

problems or concerns? 

Doctor 

communication 

(negative 

behaviors) 

In the last 12 months, how often did this doctor interrupt you when you were talking? 

In the last 12 months, how often did this doctor speak too fast when talking with you? 

In the last 12 months, did this doctor ever use a condescending, sarcastic, or rude tone or manner with you? 

Trust Do you feel you can tell this doctor anything, even things that you might not tell anyone else? 

Do you trust this doctor with your medical care? 

Do you feel this doctor always tells you the truth about your health, even if there is bad news? 

Do you feel this doctor cares as much as you do about your health? 

In the last 12 months, how often did you feel this doctor really cared about you as a person? 

100 
APPENDIX A: AMBULATORY CARE SETTING 

AMBULATORY CARE MEASURES 

MEASURE ITEMS 

Access to 

interpreter services 

In the last 12 months, did you use friends or family members as interpreters because there was no other interpreter 

available at this doctor’s office? 

In the last 12 months, how often did your visit with this doctor start late because you had to wait for an interpreter? Do not 

include friends or family members. 

In the last 12 months, was there any time when you needed an interpreter and did not get one at this doctor’s office? Do 

not include friends or family members. 

Doctor 

communication 

(health promotion) 

In the last 12 months, did you and this doctor talk about a healthy diet and healthy eating habits? 

In the last 12 months, did you and this doctor talk about the exercise or physical activity you get? 

In the last 12 months, did you and this doctor talk about things in your life that worry you or cause you stress? 

In the last 12 months, did this doctor ever ask you whether there was a period of time when you felt sad, empty, or 

depressed? 

Doctor 

communication 

(alternative 

medicine) 

In the last 12 months, has this doctor ever asked you whether you have used these other people to help with an illness or to 

stay healthy (e.g., acupuncturist or herbalist)? 

In the last 12 months, has this doctor ever asked you whether you used natural herbs? 

Shared 

decisionmaking 

In the last 12 months, did this doctor talk with you about the pros and cons of each choice for your treatment or health 

care? 

In the last 12 months, when there was more than one choice for your treatment or health care, did this doctor ask which 

choice you thought was best for you? 

Equitable 

treatment 

In the last 12 months, how often have you been treated unfairly at this doctor’s office because of your race or ethnicity? 

In the last 12 months, how often have you been treated unfairly at this doctor’s office because of the type of health 

insurance you have or because you do not have health insurance? 

101 
APPENDIX A: AMBULATORY CARE SETTING 

AMBULATORY CARE MEASURES 

MEASURE ITEMS 

CG-CAHPS CAHPS surveys ask consumers and patients to report on and evaluate their experiences with health care. The CG-CAHPS 

Survey assesses patients’ experiences with health care providers and staff in doctors’ offices. The CG-CAHPS Survey produces 

the following measures of patient experience: getting timely appointments, care, and information; how well providers 

communicate with patients; providers’ use of information to coordinate patient care; helpful, courteous, and respectful 

office staff; and patients’ rating of the provider. 

Getting timely 

appointments, 

care, and 

information 

Patient got an appointment for urgent care as soon as needed 

Patient got an appointment for nonurgent care as soon as needed 

Patient got an answer to medical question the same day he or she contacted provider’s office 

Providers’ use of 

information to 

coordinate patient 

care 

Provider knew important information about the patient’s medical history 

Someone from the provider’s office followed up with the patient to give results of blood test, X-ray, or other test 

Someone from the provider’s office talked about all prescription medications being taken 

102 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Appendix B 

Behavioral Health Setting
 

Behavioral health refers to mental and emotional well-being and/or actions that affect wellness. It includes mental and substance use disorders. Services for behavioral health are somewhat unique in that they can be provided in a range of health care settings, including inpatient 

psychiatric hospitals, psychiatric units of general acute care hospitals, inpatient residential 

treatment facilities, day treatment programs, individual provider or group behavioral health 

practices, community mental health centers, and rehabilitation programs. Increasingly, behavioral health services are also being provided in the general medical and primary care sector, such 

as outpatient or ambulatory care clinics, physician offices, or community health centers (HHS, 

2001).1 

1

 The human services sector (e.g., social welfare, including housing, transportation, and employment; criminal justice; educational, religious, 

and charitable services) also delivers mental health services in a range of settings, including in the home, community, and institutions. 

There is also the voluntary support network largely found in the community, which includes self-help groups and organizations devoted to 

education, communication, and support (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). 

In addition, behavioral health care can be provided by a diverse set of providers, including 

specialty providers (e.g., psychiatrists, psychologists, psychiatric nurses) and licensed clinical 

therapists, social workers, counselors, and nurses who have received specialized training in 

treating behavioral health concerns. Providers with training in general health care, such as 

internists, family practitioners, pediatricians, physician assistants, and nurse practitioners, may 

also provide mental health and substance abuse services as part of routine care. Although 

behavioral health services are increasingly provided in ACSs, the logic model described in this 

chapter focuses specifically on those settings that provide specialty care for behavioral health. 

In 2010, there were 10,374 specialty mental health treatment facilities and 13,339 specialty 

substance abuse treatment facilities in the United States. 

103 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 


In the United States, mental and substance use disorders are among the top conditions that 

cause disability and carry a high burden of disease. According to SAMHSA, by 2020, mental 

and substance use disorders will surpass all physical diseases as a major cause of disability 

(SAMHSA, 2016b). In 2014, an estimated 9.8 million U.S. adults (ages 18 and older) had a serious 

mental illness, with 15.7 million adults and 2.8 million youth (ages 12 to 17) having had a major 

depressive episode during the past year (SAMHSA, 2012). In addition, an estimated 22.5 million 

Americans ages 12 years and older self-reported needing treatment for alcohol or illicit drug use, 

and 11.8 million adults self-reported needing mental health treatment or counseling in the past 

year (SAMHSA, 2016b). Despite this high prevalence, nearly 60 percent of adults with a mental 

illness and 90 percent of people with a substance use disorder do not receive the care they need 

(National Alliance on Mental Illness, undated; Sebelius, 2013). 

In the United States, minority and low-income groups, as well as those living in rural areas, 

are more likely to have unmet behavioral health needs (National Institute of Mental Health 

[NIMH], undated; AHRQ, 2013a). Studies have shown, for example, that members of racial and 

ethnic minority groups are less likely to have access to mental health services (Wang et al., 2005) 

and less likely to seek or use community mental health services, compared with the general U.S. 

population (Samnaliev, McGovern, and Clark, 2009; Mulia, Tam, and Schmidt, 2014; Alegria et 

al., 2008). Minorities who do seek services for behavioral health conditions are more likely to 

receive lower-quality care (e.g., misdiagnoses [Alegria et al., 2008]) and are less likely to adhere 

to treatment plans (HHS, 2001). Although changes in how and where behavioral health care is 

delivered (e.g., primary care, telemedicine) and in who is delivering it may help address some of 

the current disparities in behavioral health care, significant work remains; this concern prompted 

104 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 


NIMH to include mental health disparities as a cross-cutting research theme in its 2015 

Strategic Plan for Research. 

Addressing disparities in behavioral health can be particularly challenging given the 

stigma surrounding it, as well as personal or cultural beliefs around the causes and 

treatment of mental health concerns. Communicating behavioral health symptoms, 

including thoughts and feelings, can also be challenging, particularly if there are cultural 

differences or language barriers between individuals and providers. Improving culturally 

and linguistically appropriate services within behavioral health settings may help reduce 

health inequities by improving the likelihood of help-seeking behaviors, improving 

perceptions about the value of behavioral health services and the likelihood of receiving 

high-quality care, improving communication and adherence to treatment protocols, and 

increasing patient satisfaction (Barksdale et al., 2012). 

105 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE BEHAVIORAL HEALTH SETTING 

Figure B.1 provides a detailed logic model of the specific inputs, activities, outputs, and 


outcomes for the implementation of the National CLAS Standards within the behavioral 


health setting. Given the importance of the broader context, external resources, and 


partnerships in shaping a behavioral health provider’s readiness for adopting the National CLAS Standards, we include these items in the context, antecedents, and inputs 


section. Any changes should be made in partnership with the community and other 


stakeholders. 


CONTEXT, ANTECEDENTS, AND INPUTS 

Linkages with the Community and Other Stakeholders 

As shown in Figure B.1, linkages with the community and other stakeholders who can 


inform, support, and partner with the behavioral health organization at all stages in the 


process of adopting the National CLAS Standards (e.g., assessment, design, implementation, evaluation) are essential. In addition to engaging with other care settings that 


provide behavioral health (e.g., ACSs, hospitals), other community sectors and settings 


provide services and supports that can supplement behavioral health services. For example, social welfare systems (e.g., housing, transportation, employment) and the criminal 


and juvenile justice systems help individuals connect to care. They may be particularly 


important partners because they also serve individuals who may be more likely to have 


unmet behavioral health needs. Schools may be another important community stakeholder and partner, particularly for reaching children and families. Charitable and faith-


based organizations, voluntary support networks (e.g., self-help groups), and advocacy 


106 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE BEHAVIORAL HEALTH SETTING 

groups are also important stakeholders because they are often trusted organizations that are 

well-integrated into the community and may offer education, communication assistance, and 

support (SAMHSA, 2012). Given this diversity, behavioral health organizations should consider 

how they work with their partners, with community organizations, and with contracted organizations: doing so may influence their overall performance with respect to implementing the 

National CLAS Standards. 

Payers are another example of key stakeholders for behavioral health settings. Publicly 

funded sources—Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP), and 

other federal and state mental health authorities—are the predominant payers of behavioral 

health services in the United States. Together, these payers contributed more than $75.4 billion 

in 2003, or about 62 percent of total behavioral health spending. At 26 percent, Medicaid 

represented the largest payer of behavioral health services (Medicaid and CHIP Payment and 

Access Commission [MACPAC], 2015). Of the public payers, states pay for behavioral health 

services through state appropriations for non-Medicaid services, block grant spending, and the 

state’s match for Medicaid and SCHIP programs. For fiscal year 2003, the states’ share of total 

behavioral health spending was $42.3 billion, or 35 percent of total spending among all payers, 

while private insurance represented 21.8 percent of behavioral health expenditures (Schwalbe, 

2010). 

107 
RAND RR2157-5.1

APPENDIX B: BEHAVIORAL HEALTH SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN THE BEHAVIORAL HEALTH SETTING
 

FIGURE B.1. IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN THE BEHAVIORAL HEALTH SETTING 

Outcomes and Impacts Proposed Changes and Strategies to Context, Antecedents, and Inputs Outputs Implement Those Changes Longer Term Shorter Term 

Community/stakeholders 

• Public and private mental health clinics 

• Psychiatric and general acute care hospitals 

• Residential treatment facilities 

• Community mental health centers 

• Ambulatory care centers 

• Behavioral health or managed care 

organizations (BHOs, MCOs) 

• FQHCs 

• Social services 

• National Alliance on Mental Illness (NAMI), 

mental health advocacy groups 

• Other 

Environmental/policy context 

• Accreditation/Joint Commission guidelines 

• Payment models 

• Title VI of 1964 Civil Rights Act 

• 2008 Paul Wellstone and Pete Domenici Mental 

Health Parity and Addiction Equity Act (MHPAEA) 

• ACA of 2010 

• Experience of Care and Health Outcomes Survey 

(ECHO) (CAHPS) 

Community/catchment area 

• Ethnicity, culture, language 

• Urban/rural 

• Engagement with behavioral health 

• Social risk factors 

• Unmet needs 

Behavioral health context/resources 

• Type (e.g., public, private, inpatient, 

outpatient, residential treatment) 

• Part of system 

• Part of network 

• Catchment area 

• Organizational structure, policies, priorities 

• Behavioral health care organizational 

resources 

• Needs assessment 

o Gaps in activities, structures, policies 

o Gaps in implementation factors 

National CLAS Standards 

Organization Organization 

Individual/Client Individual/Client 

Continuous improvement 

Diverse viewpoints from within and outside of 

the organization are incorporated in 

organizational planning and implementation of 

behavioral health policies, programs, and 

services. 

Provision of quality care and services that are 

responsive to diverse cultural health beliefs 

Organizational culture shifts to provide ongoing 

and visible support for National CLAS Standards 

Continued improvement in provision of 

high-quality public health care services related 

to National CLAS Standards 

Increased trust and engagement between 

community and behavioral health care providers 

and organizations 

Provision of more-equitable mental health 

services 

Improved behavioral health and health 

outcomes 

Provision of quality care and services that are 

responsive to preferred languages, health 

literacy, and other communication needs 

Data on race, ethnicity, sex, disability status, and 

language are used to monitor and improve 

behavioral health service delivery. 

Improved two-way communication and 

feedback mechanisms between individuals and 

behavioral health organizations 

Increased buy-in from staff on organizational 

changes 

Better and earlier detection of behavioral health 

concerns through appropriate screening 

Individuals seeking behavioral health care have 

access to high-quality language services. 

Individuals are empowered to become active 

participants in their mental health and other 

behavioral health care. 

Reduced disparities 

Increased trust between individuals seeking 

behavioral health care and treatment providers 

Improved satisfaction among individuals seeking 

mental health and other behavioral health care 

Improved mental health, family and social 

functioning, and overall well-being 

Increased use of appropriate behavioral health 

care services with regular follow-up and 

continuity of care 

Individuals are better able to access and 

navigate behavioral health care services. 

Individuals are better able to understand 

behavioral health and other treatment options 

and make informed care decisions. 

Greater adherence to medication and treatment 

protocols 

National CLAS Standards are built into 

organization’s mission, goals, and policies, and 

are central to the organization’s functions. 

Increased knowledge and skills for all staff 

related to delivering culturally and linguistically 

appropriate care at all levels of the organization 

Organization has ethnically diverse providers and 

staff at all levels. 

Standards of practice implemented around clear 

communication, access to language services, and 

notification of rights 

Staff understand the benefit of implementing 

National CLAS Standards for the organization 

and the individuals it serves. 

Transparency within and outside organization 

with respect to implementing National CLAS 

Standards 

Improvement in physical layout, signage, ease of 

access, and navigation 

Resources and accountability to support/sustain 

initiatives and efforts related to National CLAS 

Standards, including languages services 

Improved collection of, access to, geographic 

mapping of, and dissemination of accurate 

population data, particularly for ethnic and 

minority populations 

An understanding of the assets and needs of the 

organization and service area is achieved. 

Changes to 

organizational 

policies 

Changes to 

processes 

and 

practices 

Changes to 

structure, 

staffing, and 

resources 

108 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE BEHAVIORAL HEALTH SETTING 

Environmental and Policy Context 

Implementation of the National CLAS Standards within a behavioral health organization is 

affected by a number of factors external to the organization itself. These factors include, for 

example, the federal, state, and local regulatory environment; accreditation mandates; policies; 

and standards of practice. In many cases, these factors influence how care is delivered and monitored and may affect whether and how organizations may choose to adopt the Standards. 

In 1996, Congress enacted the Mental Health Parity Act (MHPA), which required parity in 

aggregate lifetime and annual dollar limits for mental health benefits and medical/surgical 

benefits. The MHPAEA (or the federal parity law) generally prevents group health plans and 

health insurance issuers that provide mental health or substance use disorder benefits from 

imposing less-favorable benefit limitations on those benefits than on medical/surgical benefits. 

The changes made by MHPAEA consisted of new standards, including parity for coverage of 

substance use disorder benefits and amendments to the existing mental health parity provisions 

enacted in MHPA.2 

2

 CMS’s mental health and substance use disorder parity final rule for Medicaid and the Children’s Health Insurance Program (CHIP) applies 

certain provisions of the MHPAEA to requirements for Medicaid managed care organizations, Medicaid alternative benefit plans, and CHIP. 

Specifically, the final rule requires that all beneficiaries who receive services through managed care organizations, alternative benefit plans, 

or CHIP be provided access to mental health and substance use disorder benefits that comply with parity standards, regardless of whether 

these services are provided through the managed care organization or another service delivery system. States are required to include 

contract provisions requiring compliance with parity standards in all applicable contracts for these Medicaid managed care arrangements 

that provide services to enrollees in managed care organizations, including prepaid inpatient health plans or prepaid ambulatory health 

plans. 

109 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE BEHAVIORAL HEALTH SETTING 

Of particular importance is the ACA, which represented a significant expansion of mental 

health and substance use disorder coverage. The ACA amended the MHPAEA—which originally 

applied to group health plans and group health insurance coverage—so that it also applied 

to individual health insurance coverage. Additionally, beginning in 2014, the ACA required 

nongrandfathered individual and small-group plans (including those in the state and federal 

marketplace) to provide coverage for mental health and substance use disorder services as 

one of ten essential health benefit categories and to cover them at parity with medical and 

surgical benefits. It is estimated that through the ACA, 32.1 million Americans will gain access to 

coverage that includes mental health and/or substance use disorder benefits that comply with 

federal parity requirements and that an additional 30.4 million Americans who currently have 

some mental health and substance use disorder benefits will benefit from the federal parity 

protections (Beronio et al., 2013). HHS has jurisdiction over public-sector group health plans 

(referred to as “non-Federal governmental plans”), while the U.S. Departments of Labor and the 

Treasury have jurisdiction over private group health plans. 

There are also various existing cultural competency guidelines that have been developed for 

the behavioral health sector, two of which we highlight here. First, the American Psychological 

Association’s Guidelines on Multicultural Education, Training, Research, Practice, and 

Organizational Change for Psychologists provides the rationale and the background information 

that supports the Association’s six guidelines, as well as resources to enhance education, 

training, research, practice, and organizational change methodologies (American Psychological 

Association, 2002). Of particular relevance are Guideline 5, which addresses applying culturally 

appropriate skills in clinical and other applied psychological practices, and Guideline 6, which 

110 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE BEHAVIORAL HEALTH SETTING 

encourages psychologists to use organizational change processes to support culturally informed 

organizational policies and practices. SAMHSA (2015) also provides guidance on applying cultural 

competence in each step of its Strategic Prevention Framework.

3

3

 SAMHSA’s framework draws on the National Center for Cultural Competence at Georgetown University’s Center for Child and Human 

Development’s 2005 guidance, which outlines the characteristics of culturally competent organizations and describes the six stages of 

Infusing Cultural and Linguistic Competence in Health Promotion Training (National Center for Cultural Competence, undated). 

 These guidelines are similar to the 

National CLAS Standards in their fundamental principles; however, the Standards outline specific 

action steps that health organizations or HCOs, including behavioral health care organizations, 

can undertake to implement culturally and linguistically appropriate services. The National CLAS 

Standards are intended to help organizations operationalize cultural and linguistic competency 

principles and implement them in their overall organizational culture (Barksdale et al., 2012). 

These examples of external influences and contexts may impact whether and how behavioral 

health settings will adopt the National CLAS Standards and how easy or difficult such 

implementation may be. 

Context, resources, community, and catchment area inputs and antecedents relevant to 

implementation of the National CLAS Standards for behavioral health organizations include the 

organization’s strategic goals, policies, staff, resources, and physical environment. They can vary 

considerably depending on the type of behavioral health setting (e.g., public, for-profit, nonprofit) 

and on whether the behavioral health organization is part of a system or network (e.g., behavioral 

health managed care network). Inputs and antecedents may also be driven by the catchment area 

of the facility and whether that facility serves a geographic area or a specific population (e.g., 

low-income populations, racially/ethnically diverse populations) or is focused on mental health 

treatment services, substance abuse treatment services, or both. Other factors influencing the 

111 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE BEHAVIORAL HEALTH SETTING 

organization’s inputs and antecedents include internal and external factors. Internal factors— 

such as the proportion of patients with Medicare, Medicaid, or private insurance as well as the 

uninsured—can affect resource availability. External factors, such as competition, can provide an 

impetus for cultural competency activities as behavioral health organizations strive to increase or 

maintain their market share in an increasingly diverse population. 

Also relevant is the organization’s capacity to absorb new knowledge and its receptivity 

for change, which may be driven by a gap analysis or a needs assessment. This analysis should 

include both an assessment of activities, structures, or policies that should be in place to support 

equitable care, as well as implementation factors that could aid or hinder the adoption of the 

National CLAS Standards. A behavioral health needs assessment may also identify gaps in a 

community’s mental health and substance use services system for non-English speakers, helping 

to inform the prioritization of strategies and activities to address needs in the community. 

NATIONAL CLAS STANDARDS 

In this logic model, the National CLAS Standards are placed between the antecedents and inputs 

and the activities an organization adopts. Here, the National CLAS Standards are viewed as a 

perspective or lens through which such context and antecedents are interpreted and help to 

shape the activities the organization chooses to implement to address gaps in culturally and 

linguistically appropriate care. 

112 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE BEHAVIORAL HEALTH SETTING 

PROPOSED CHANGES AND STRATEGIES DEVELOPED TO IMPLEMENT 

THOSE CHANGES 

Behavioral health organizations may adopt the National CLAS Standards altogether or in a 

staged approach, depending on the antecedents and inputs, readiness for implementation, 

available resources, and the environmental and policy context. Given the wide range of potential approaches and activities behavioral health organizations may choose to develop or adopt, 

the logic model does not list specific activities; rather, it notes that changes are likely to occur 

in three nested areas of focus: (1) organizational policies; (2) structure, staffing, and resources; 

and (3) processes and practices. The identification of organizational gaps and priorities and the 

design, development, and implementation of activities to address those gaps are expected to be 

undertaken with input from the community and other stakeholders that stand to benefit from 

such changes. 

113 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE BEHAVIORAL HEALTH SETTING 

OUTPUTS 

The activities and changes implemented within the organization should result in immediate outputs that move the organization closer to providing culturally and linguistically appropriate care 

and services. Such outputs may include the following: 

•	 incorporating diverse viewpoints from inside and outside the behavioral health 

organization into the planning and implementation of policies, programs, and services 

•	 building the National CLAS Standards into the organization’s mission, goals, and policies 

and making them central to its functions 

•	 implementing standards of practice around clear communication, access to language 

services, and notification of rights 

•	 increasing staff knowledge and skills related to delivering culturally and linguistically 

appropriate care at all levels of the organization 

•	 incorporating ethnically diverse practitioners and staff at all levels of the behavioral 

health organization 

•	 improving the physical layout, signage, ease of access, and navigation 

•	 improving the collection of, access to, geographic mapping of, and dissemination of 

accurate population data, particularly for ethnic and minority populations 

•	 ensuring that resources and accountability to support and sustain initiatives and efforts 

related to the National CLAS Standards are available. 

114 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE BEHAVIORAL HEALTH SETTING 

The specific outputs expected will be determined by which of the National CLAS Standards have 

been adopted, by which organizational changes have been made, and by which activities have 

been implemented as a result. 

OUTCOMES 

Collectively and over time, outputs from behavioral health organizations may contribute to 

changes in outcomes for both individuals using these services and for the organization overall. 

Examples of potential outcomes within the behavioral health setting are listed below. 

• For the organization 

– Short term (1–2 years) 

> the provision of effective, equitable, understandable, respectful, and quality 

care and behavioral health services that are responsive to diverse cultural 

health beliefs and practices, preferred languages, health literacy, and other 

communication needs 

> the use of data on race, ethnicity, sex, sexual orientation, disability status, and 

language to monitor and improve behavioral health service delivery 

> racial/ethnic and linguistic concordance between behavioral health service 

providers and individuals seeking mental health and/or substance use treatment 

services 

> improved two-way communication and feedback mechanisms between 

individuals and behavioral health organizations 

115 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE BEHAVIORAL HEALTH SETTING 

> increased buy-in from staff on organizational changes made to implement the 

National CLAS Standards. 

– Longer term (3 or more years) 

> organizational culture shifts to provide ongoing and visible support for the 

National CLAS Standards within behavioral health care organizations 

> continued improvement in the provision of high-quality behavioral health care 

services related to the Standards 

> improved behavioral health and health outcomes 

> increased equity in access to high-quality behavioral health services and a 

reduction in health disparities 

> increased trust and engagement between the community and behavioral health 

care providers and organizations. 

• For the individuals seeking care 

– Short term (1–2 years) 

> individuals seeking specialty behavioral health care have access to high-quality 

language services 

> individuals are better able to access and navigate specialty behavioral health care 

services 

> individuals are better able to understand mental health and other treatment 

options and make informed behavioral health care decisions 

> greater adherence to medication and treatment protocols. 

116 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX B: BEHAVIORAL HEALTH SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE BEHAVIORAL HEALTH SETTING 

– Longer term (3 or more years) 

> individuals are empowered to become active participants in their behavioral health care 

> improved satisfaction among individuals seeking mental health and other behavioral 

health care 

> increased trust between individuals seeking behavioral health care and providers and 

between the community and behavioral health care organizations 

> increased use of appropriate behavioral health care services with regular follow-up and 

continuity of care 

> improved behavioral health, family and social functioning, and overall well-being. 

QUALITY IMPROVEMENT 

The logic model also depicts the adoption and implementation of the National CLAS Standards as a 

continual process, requiring a QI loop. For example, behavioral health organizations can assess their 

performance by applying for Behavioral Health Accreditation (The Joint Commission, 2007), psychologists can assess how well they are following the APA Guidelines, and consumers can provide feedback 

on their experiences with behavioral health treatment using the ECHO survey.4

4

 Similar to the CAHPS Survey that asks consumers and patients to report on and evaluate their experiences with health care, the ECHO 

survey asks for consumers’ assessments about their behavioral health treatment, including mental health and chemical dependency services. 

The ECHO survey asks health plan enrollees about their experiences with behavioral health care and services provided by either managed 

behavioral health care organizations (MBHOs) or managed care organizations. It is designed for use by consumers, clinicians, MBHOs, health 

care plans, purchasers, states, and federal agencies. The ECHO survey’s contents were largely derived from two preexisting instruments for 

behavioral health care quality assessment: the Mental Health Statistics Improvement Program, and the Consumer Assessment of Behavioral 

Health Services surveys (AHRQ, 2016). 

 All of these tools may 

be helpful to assess the success and effectiveness of the implementation of the National CLAS Standards. 

117 
APPENDIX B: BEHAVIORAL HEALTH SETTING 


BEHAVIORAL HEALTH MEASURES 

TABLE B.1. BEHAVIORAL HEALTH MEASURES 

MEASURE DESCRIPTION AREA OF FOCUS SOURCE ID NOTES REFERENCE 

ECHO survey The ECHO survey asks about the experiences of adults and children 

who have received mental health or substance abuse services through a 

health plan in the previous 12 months. It is appropriate for patients with 

a range of service needs, including those with severe mental illness, but 

does not include questions about inpatient stays or self-help groups. The 

survey can be used for two types of organizations that are responsible 

for delivering behavioral health services: MCOs and MBHOs. 

Patient 

experience 

ECHO See Table 

E.2 for list of 

measures. 

AHRQ, 2016 

Disparity-sensitive measures or CLAS-salient measures 

Alcohol 

screening and 

follow-up 

for people 

with serious mental 

illness 

The percentage of patients ages 18 and older with a serious mental 

illness who were screened for unhealthy alcohol use and received brief 

counseling or other follow-up care if identified as an unhealthy alcohol 

user 

Primary 

prevention 

NQF 

#2599 

(measure 

steward: 

NCQA) 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: 

“2599”) 

Initiation 

and engagement 

of alcohol 

and other 

drug dependence 

treatment 

Percentage of patients ages 13 and older with a new episode of alcohol 

and other drug (AOD) dependence who received the following. Two 

rates are reported: 

1. percentage of patients who initiated treatment within 14 days of 

the diagnosis 

2. percentage of patients who initiated treatment and who had two 

or more additional services with an AOD diagnosis within 30 days 

of the initiation visit. 

Effective 

communication 

and Care 

coordination 

NQF #4 

(measure 

steward: 

NCQA) 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: “4”) 

NQF, 2008 

118 
APPENDIX B: BEHAVIORAL HEALTH SETTING 

BEHAVIORAL HEALTH MEASURES 

MEASURE DESCRIPTION AREA OF FOCUS SOURCE ID NOTES REFERENCE 

Antidepressant 

medication 

management 

(AMM) 

The percentage of patients ages 18 and older with a diagnosis of major 

depression and were newly treated with antidepressant medication and 

who remained on an antidepressant medication treatment. Two rates are 

reported: 

1. effective acute phase treatment: the percentage of newly diagnosed and treated patients who remained on an antidepressant 

medication for at least 84 days (12 weeks) 

2. effective continuation phase treatment: the percentage of newly 

diagnosed and treated patients who remained on an antidepressant medication for at least 180 days (6 months). 

Effective 

communication and care 

coordination 

NQF #105 

(measure 

steward: 

NCQA) 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: 

“105”) 

NQF, 2008 

30-day allcause unplanned readmission 

following 

psychiatric 

hospitalization in an 

inpatient 

psychiatric 

facility (IPF) 

This facility-level measure estimates an all-cause, unplanned, 30-day 

risk-standardized readmission rate (RSRR) for adult Medicare Fee-forService (FFS) patients with a principal discharge diagnosis of a psychiatric 

disorder or dementia/Alzheimer’s disease. 

Effective 

communication and care 

coordination 

NQF 

#2860 

(measure 

steward: 

CMS) 

NQF, 

undated 

(search: 

“2860”) 

SAMHSA, 

2014b 

119 
APPENDIX B: BEHAVIORAL HEALTH SETTING 


BEHAVIORAL HEALTH MEASURES
 

TABLE B.2. BEHAVIORAL HEALTH MEASURES: ADDITIONAL DETAIL
 

MEASURE ITEMS 

ECHO survey The ECHO survey asks about the experiences of adults and children who have received mental health or substance abuse 

services through a health plan in the previous 12 months. It is appropriate for patients with a range of service needs, 

including those with severe mental illness, but does not include questions about inpatient stays or self-help groups. The 

survey can be used for two types of organizations that are responsible for delivering behavioral health services: MCOs and 

MBHOs. 

Getting treatment 

quickly (composite) 

Q3: Get help by telephone 

Q5: Get urgent treatment as soon as needed 

Q7: Get appointment as soon as wanted 

How well clinicians 

communicate 

(composite) 

Q11: Clinicians listen carefully 

Q12: Clinicians explain things 

Q13: Clinicians show respect 

Q14: Clinicians spend enough time 

Q15: Feel safe with clinicians 

Q18: Involved as much as you wanted in treatment 

Getting treatment 

and information 

from the plan or 

MBHO (composite) 

Q43: (MCO only) Getting clinician happy with 

Q39: (MBHO)/Q45 (MCO) Delays in treatment while waiting for plan approval 

Q46: (MCO only) Problem getting necessary treatment 

Q48: (MCO only) Understanding information about treatment in written materials or on the Internet 

Q41: (MBHO)/Q50 (MCO) Helpfulness of customer service 

Q52: (MCO only) Filling out paperwork 

Perceived 

improvement 

(composite) 

Q31: Compare ability to deal with daily problems to one year ago 

Q32: Compare ability to deal with social situations to one year ago 

Q33: Compare ability to accomplish things to one year ago 

Q34: Compare ability to deal with symptoms or problems to one year ago 

120 
APPENDIX B: BEHAVIORAL HEALTH SETTING 

BEHAVIORAL HEALTH MEASURES 

MEASURE ITEMS 

Information about 

treatment options 

(composite) 

Q20: Told about self-help or consumer-run programs 

Q21: Told about different treatments that are available for condition 

Rating of 

counseling and 

treatment 

Q28: Overall rating of counseling and treatment 

Rating of health 

plan (MCO only) 

Q53: (MCO only) Overall rating of health plan 

Office wait Q10: Seen within 15 minutes of appointment time 

Told about 

medication side 

effects 

Q17: Told about side effects of medication 

Including family 

and friends 

Q19: Talk about including family and friends in treatment 

Information to 

manage condition 

Q22: Given as much information as wanted to manage condition 

Patient rights 

information 

Q23: Given information about rights as a patient 

Patient feels he or 

she could refuse 

treatment 

Q24: Patient feels that he or she could refuse a specific type of treatment 

121 
APPENDIX B: BEHAVIORAL HEALTH SETTING 

BEHAVIORAL HEALTH MEASURES 

MEASURE ITEMS 

Privacy Q25: Confident about privacy of treatment information 

Cultural 

competency 

Q27: Care responsive to cultural needs 

Amount helped Q29: Amount helped by treatment 

Treatment after 

benefits are used 

up 

Q37: (MBHO)/Q41 (MCO) Plan provides information about how to get treatment after benefits are used up 

122 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Appendix C
 

Hospital Setting 

There are more than 5,500 registered hospitals in the United States, the majority of which are 

community hospitals. These consist of nonprofit, for-profit, or state and local government community hospitals (American Hospital Association [AHA], 2016). Other hospital types include federal 

government hospitals, psychiatric hospitals, and long-term care hospitals. In 2011, hospitals collectively conducted more than 125.7 million outpatient visits (CDC, National Center for Health Statistics 

[NCHS], 2016) and were responsible for about 35 million hospital discharges from inpatient care 

(CDC NCHS, 2016). While hospitals have traditionally focused on meeting the clinical needs of their 

patients through patient safety and high-quality care (The Joint Commission, 2010), such patient 

characteristics as language, culture, and other nonclinical needs can affect how individuals approach 

and participate in health care while in the hospital and during critical periods of transition, such as 

discharge. 

Hospitals across the United States are increasingly serving diverse patient populations; some 

may have LEP or non-English proficiency. Findings from a national survey of hospitals revealed 

that 63 percent of hospitals reported encountering patients with LEP on a daily or weekly basis 

(Hasnain-Wynia et al., 2006). A 2009 survey of hospitals indicated that while 92 percent provided 

language services, about one-quarter used only one modality for providing such services. The most 

commonly used services are either over-the-phone interpreting services or the use of hospitals’ own 

bilingual staff as interpreters. Often, these bilingual staff have not been assessed for their linguistic 

proficiency nor trained on interpreting skills. In addition to the limitations in interpreting services, 

only 55 percent of respondents indicated that their hospital provided translation services of written 

documents (CyraCom, 2010). Similarly, a 2012 national survey by the AHA and the Institute for 

Diversity in Health Management (IFD) indicated that hospitals’ attention to diversity management 

and cultural competence practices are somewhat limited. While 77 percent of responding hospitals 

t 123 u
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 


collected patient demographic data, only 18 percent used these data to benchmark gaps in 

care. Fewer than half provided comprehensive cultural competence training (AHA and IFD, 

2012). Providing culturally and linguistically competent care is crucial to ensuring a satisfactory 

patient experience, effective communication between patients and providers, and positive 

treatment outcomes (Gertner et al., 2010). If culturally and linguistically appropriate services 

are not provided in hospitals, patients may not be able to communicate effectively with their 

providers or adhere to care plans, hospitals will continue to put themselves and their patients 

at risk for negative consequences, and racial and ethnic disparities in health care may continue 

to increase (Wilson-Stronks and Galvez, 2007; The Joint Commission, 2010). Furthermore, given 

the increased emphasis on value-based care in our reimbursement system and paying for quality, 

hospitals that are not responsive to the cultural and linguistic needs of the patient population 

may see a negative impact on their financial performance. 

One example of how providing culturally and linguistically appropriate care can improve 

quality while financially benefiting the hospital relates to readmissions. Hospitals are now 

being penalized for excess readmissions for several acute conditions, such as acute myocardial 

infarction (AMI), health failure, and pneumonia. Betancourt, Tan-McGrory, and Kenst (2015) 

have outlined several issues related to cultural and linguistic competence that may play a 

key role in driving higher readmission rates among diverse patient populations. For instance, 

having LEP is associated with lower rates of follow-up, use of preventive services, adherence 

to medications, and comprehension of discharge instructions and diagnosis, which may be tied 

to readmissions (Rodriguez et al., 2011; Karliner et al., 2012). Health literacy–related issues— 

including limited knowledge of conditions, poor medication management and self-care, and 

124 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 


lack of adherence to treatment plans—may also influence readmission rates among minorities 

(Berkman et al., 2011; Evangelista et al., 2010; Mitchell et al., 2012). Additionally, cultural factors 

may contribute to readmissions. In particular, cultural beliefs and customs can impact patients’ 

health behaviors, care perceptions, and understanding of medical information or advice (Li et 

al., 2006; Davidson et al., 2007; Dickson et al., 2013). Implementing culturally and linguistically 

competent care and activities may effectively address the aforementioned issues, thus lowering 

hospital readmission rates and costs. 

Brach and Fraser (2002) have presented the business case for cultural competency and have 

identified four interrelated financial incentives for cultural competency in hospitals. 

•	 Cultural competency increases the hospital’s appeal to diverse populations and thus 


increases its market share. This is particularly critical as the U.S. population becomes 


increasingly diverse. 


•	 Cultural competency can improve the performance of hospitals in publicly reported quality 


and patient experience measures. This is important given that value-based purchasing 


reimbursement is increasingly tied to these metrics. A study by Weech-Maldonado et al. 


(2012c) shows a positive relationship between adherence to the National CLAS Standards 


and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores 


among hospitals. 


•	 Public purchasers, such as Medicaid and Medicare, increasingly are instituting cultural 


competency requirements in their contracts. Hospitals must comply with these 


requirements to maintain their contracts with public purchasers. 


•	 There is the potential to reduce costs by reducing medical errors, complications, and 


readmissions. This is particularly important in the context of value-based reimbursement 


and ACOs.
 

125 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE HOSPITAL SETTING 

Figure C.1 provides a detailed logic model of the specific inputs, activities, outputs, and outcomes 

for the implementation of the National CLAS Standards within the hospital setting. Given the 

importance of the broader context and external resources and partnerships to shape a hospital’s 

readiness for adopting the Standards, we include them in the context, antecedents, and inputs 

column and note that any changes should be made in partnership with the community and other 

stakeholders. 

CONTEXT, ANTECEDENTS, AND INPUTS 

Linkages with the Community and Other Stakeholders 

Hospitals have a number of collaborative relationships and partnerships with community entities 

to understand and address the cultural and linguistic needs of the communities they serve 

(Wilson-Stronks and Galvez, 2007; Weech-Maldonado and Merrill, 2000). These partnerships include educational, social service, religious, and public health organizations, as well as other hospitals and providers that may provide specialty care for their patients. For example, hospitals may 

work with alternative medicine providers to augment allopathic treatments and avoid complications from incompatible therapies (Brach and Fraser, 2000). Such linkages may also include liaisons 

with trusted members of the community, such as community health workers or promotores de 

salud (Rural Health Information Hub, 2011; The Lewin Group, 2002; Brach and Fraser, 2000). Furthermore, hospitals may have a direct presence in the community through hospital-owned primary 

care practices. These linkages are particularly important as hospitals seek to improve transitions in 

care for patients discharged from the hospital, with the goal of reducing readmissions and unnecessary Emergency Department use. In addition, these linkages are critical given the emergence 

126 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE HOSPITAL SETTING 

of ACOs, where hospitals are assuming risk for the duration of care. This has increased the focus 

of hospitals on population health and the social determinants of health and has resulted in an 

increased awareness of the importance of community linkages. 

Hospitals may also be connected to other provider stakeholders (e.g., physicians and other 

health care providers) through ACOs. ACO arrangements focus on forming provider networks to 

coordinate care delivery. Since ACOs may be rewarded based on their ability to improve quality 

and reduce costs, implementing the National CLAS Standards may provide an opportunity to 

reach these goals (Adepoju, Preston, and Gonzales, 2015). Hospitals should consider how they 

work with partners and contracted organizations with respect to meeting the diverse cultural 

and linguistic needs of their patient populations because this may influence their own overall 

performance with respect to the National CLAS Standards. 

Other stakeholders include payers and employers. Rising health care costs, coupled with the 

oftentimes subpar quality of care in the United States, is resulting in an increased emphasis on 

value-based care, or paying for value rather than volume. As such, both payers and employers 

can be partners in hospital efforts to increase cultural competency activities, which may result 

in higher-quality care at lower costs for diverse patient populations. Such partners should 

be involved at all stages of Standards adoption (e.g., assessment, design, implementation, 

evaluation). 

127 
RAND RR2157-4.1

APPENDIX C: HOSPITAL SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN THE HOSPITAL SETTING 

FIGURE C.1. LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN THE HOSPITAL SETTING 

Outcomes and Impacts Proposed Changes and Strategies to Context, Antecedents, and Inputs Outputs Implement Those Changes Longer Term Shorter Term National CLAS Standards 

Organization Organization 

Individual/Client Individual/Client 

Continuous improvement 

Diverse viewpoints from within and outside of 

the organization are incorporated in 

organizational planning. Provision of quality care and services that are 

responsive to diverse cultural health beliefs 

Continued improvement in provision of 

high-quality services related to National CLAS 

Standards. 

Better patient outcomes, improved safety, 

higher-quality care, reduction in readmission 

rates 

Increased HCAHPS scores (patient experience) 

Increased equity in access to high-quality 

hospital services and a reduction in health 

disparities 

Organizational culture shifts to provide ongoing 

and visible support for National CLAS Standards. 

Provision of quality care and services that are 

responsive to preferred languages, health 

literacy, and other communication needs 

Data on race, ethnicity, sex, disability status, and 

language are used to monitor and improve 

service delivery within hospital. 

Improved two-way communication and 

feedback mechanisms between individuals and 

hospital 

Racial/ethnic/linguistic concordance between 

providers and patients 

Individuals have access to high-quality language 

services. 

Greater adherence to medications, treatment 

protocol, and follow-up after discharge 

Improved satisfaction among individuals seeking 

hospital services 

More-successful transitions to other care 

facilities (e.g., home, long-term care, nursing 

home) 

Increased trust in and engagement with the 

hospital 

Reduced hospital readmission rates 

Individuals are better able to access and 

navigate hospital services. 

Individuals are better able to understand their 

treatment options and make informed care 

decisions. 

Patients are better able to understand and 

follow pre- and postoperative or test 

instructions and discharge plans. 

Community/stakeholders 

• Physician offices, health centers, FQHCs 

• Insurers 

• Community health workers/promotores de 

salud 

• Community organizations 

o Care transitions 

o Social service 

Environmental/policy context 

• Accreditation/joint commission guidelines 

• Payment models 

• Patient-centered care 

• Triple Aim: cost, quality, experience 

• Title VI of 1964 Civil Rights Act 

• Community Health Needs Assessment (CHNA) 

for 501(c)(3) 

• HCAHPS 

• ACA 

Community/catchment area 

• Ethnicity, culture, language 

• Urban/rural 

• Engagement with hospital 

o Serve on boards, planning committees, 

provide input 

• Unmet needs 

Hospital context/resources 

• Type (e.g., community, for profit, 

nonprofit) 

• Part of system 

• Part of network 

• Catchment area: by geography, condition, 

patient type (e.g., children) 

• Organizational structure, policies, priorities 

• Hospital resources 

o Financial 

o Staff time, skills, capacities 

o Interpretation and translation services 

o Physical space, equipment 

• Needs assessment 

o Gaps in activities, structures, policies 

o Gaps in implementation factors 

National CLAS Standards are built into 

organization’s mission, goals, and policies, and 

are central to the organization’s functions. 

Increased knowledge and skills for all staff 

related to delivering culturally and linguistically 

appropriate care at all levels of the organization. 

Organization has ethnically diverse providers and 

staff at all levels, including boards and senior 

administration. 

Standards of practice implemented around clear 

communication, access to language services, and 

notification of rights 

Written information (e.g., instructions, consent 

forms, discharge paperwork) is provided in 

multiple languages. 

Transparency within and outside organization is 

attained with respect to implementation of the 

National CLAS Standards. 

Improvement in physical layout, signage, ease of 

access, and navigation 

Dedicated resources and accountability to 

support/sustain initiatives and efforts related to 

the National CLAS Standards, including language 

services 

Improved collection of, access to, geographic 

mapping of, and dissemination of accurate 

population data, particularly for ethnic and 

minority populations 

An understanding of the assets and needs of the 

organization and service area is achieved. 

Changes to 

organizational 

policies 

Changes to 

processes 

and 

practices 

Changes to 

structure, 

staffing, and 

resources 

128 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE HOSPITAL SETTING 

Environmental and Policy Context 

Implementation of the National CLAS Standards within an organization is affected by a number 

of factors external to the organization itself. These include, for example, the federal (e.g., ACA), 

state, tribal, and local regulatory environment; accreditation mandates; policies; and standards 

of practice. In many cases, these factors influence how care is delivered and monitored and may 

impact whether and how organizations may choose to adopt the Standards. 

One external factor that can affect implementation is the ACA, which contains several 

provisions related to providing culturally and linguistically appropriate care. In addition, under 

Title VI of the Civil Rights Act of 1964 (Chen, Youdelman, and Brooks, 2007), organizations 

receiving federal funds must take reasonable steps to provide meaningful access to their 

programs for individuals with LEP (Federal Register, 2000). Furthermore, several states have 

recognized the importance of cultural and linguistic competency by legislating cultural and 

linguistic competency training in health care (HHS OMH, 2016). Accrediting bodies, such as The 

Joint Commission and the NCQA, have also established accreditation standards that target the 

improvement of communication, cultural competency, patient-centered care, and the provision 

of language assistance services (Briefer French et al., 2008; HHS OMH, 2013; Wilson-Stronks and 

Galvez, 2007). 

In addition to changes in the regulatory environment, hospitals are also working within 

changes in payment models toward more value-based purchasing and toward an increasing 

emphasis on population health, which align with the National CLAS Standards. Related to 

this are the various financial penalties and rewards associated with performance on publicly 

reported measures, such as readmissions and patient experience. 

129 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE HOSPITAL SETTING 

These types of external influences and contexts may impact whether and how a hospital will 

adopt the National CLAS Standards and how easy or difficult such implementation may be for 

the hospital. 

Hospital Context, Resources, Community, and Catchment Area 

Inputs and antecedents relevant to the implementation of the National CLAS Standards can 

vary considerably depending on the type of hospital (e.g., public, for-profit, nonprofit) and 

on whether the hospital is part of a system (e.g., a group of hospitals) or network. Inputs and 

antecedents—such as the hospital’s strategic goals, policies, staff, resources, and physical environment—may also be driven by the catchment area of the hospital and whether that hospital 

serves a geographic area or a specific population (e.g., children) or is disease-specific (e.g., cancer 

center). 

Other factors influencing hospital inputs and antecedents include both internal and external 

elements. Internal factors—such as payer mix, the proportion of inpatients with Medicare, 

Medicaid, or private insurance, or the proportion uninsured—can affect resource availability. 

External factors, such as competition, can provide an impetus for cultural competency activities 

as hospitals strive to increase or maintain their market share in an increasingly diverse 

population. Weech-Maldonado and colleagues (2012c) found that hospitals in more-competitive 

markets had a higher degree of adherence to culturally and linguistically appropriate care. 

Also relevant is the organization’s capacity to absorb new knowledge and its receptivity for 

change, which may be driven, for example, by a gap analysis or needs assessment. This analysis 

should include an assessment of activities, structures, or policies that should be in place to 

support equitable care as well as implementation factors that could aid or hinder the adoption 

130 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE HOSPITAL SETTING 

of the National CLAS Standards. Of note, all nonprofit hospitals are required to complete a 

CHNA and implementation strategy (CDC, 1987). These assessments and strategies are intended 

to help hospitals obtain the information they need to provide benefits that better meet 

the needs of their communities and to provide an opportunity for coordination with other 

community services (CDC, 1987). Although not all hospitals are required to complete a CHNA, 

those that do may use such information to inform the adoption and implementation of the 

National CLAS Standards. 

NATIONAL CLAS STANDARDS 

As with the other logic models, the National CLAS Standards are placed between the antecedents and inputs and the activities an organization adopts. Again, the National CLAS Standards 

are viewed as a perspective or lens through which such context and antecedents are interpreted 

and help to shape the activities the organization chooses to implement to address gaps in culturally and linguistically appropriate care within its setting. 

PROPOSED CHANGES AND STRATEGIES DEVELOPED TO IMPLEMENT 

THOSE CHANGES 

Once an organization has decided to address identified gaps with respect to the National CLAS 

Standards, it must plan and design relevant activities and approaches to close these gaps. As was 

noted in earlier chapters in this report, organizations may adopt the National CLAS Standards 

either altogether or in a staged approach, depending on the antecedents and inputs, readiness 

131 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE HOSPITAL SETTING 

for Standards implementation, and the environmental and policy context. Given the wide range 

of potential approaches and activities a hospital may choose to develop or adopt, the logic 

model does not include specific activities; rather, it notes that changes are likely to occur in three 

nested areas of focus: (1) organizational policies; (2) structure, staffing, and resources; and (3) 

processes and practices. The identification of gaps and priorities and the design and development of activities to address those gaps are expected to be done in close collaboration with the 

community and other stakeholders that stand to benefit from such changes. 

OUTPUTS 

The activities and changes implemented within the organization should result in immediate outputs that move the organization closer to providing culturally and linguistically appropriate care 

and services. Such outputs may include the following: 

•	 incorporating diverse viewpoints from inside and outside the hospital into the planning 

and implementation of policies, programs, and services 

•	 building the National CLAS Standards into the hospital’s mission, goals, and policies and 

making them central to its functions 

•	 implementing standards of practice around clear communication, access to language 

services, and notification of rights 

•	 increasing staff knowledge and skills related to delivering culturally and linguistically 

appropriate care at all levels of the organization 

•	 incorporating ethnically diverse health care practitioners and staff at all levels of the 

hospital 

132 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE HOSPITAL SETTING 

•	 improving the physical layout, signage, ease of access, and navigation 

•	 improving the collection of, access to, geographic mapping of, and dissemination of 

accurate population data, particularly for ethnic and minority populations 

•	 targeting QI activities to disparities in access and outcomes of care 

•	 ensuring that resources and accountability to support and sustain initiatives and efforts 

related to the National CLAS Standards are available. 

The specific outputs expected will be determined by which of the National CLAS Standards 

have been adopted, by which organizational changes have been made, and by which activities 

have been implemented as a result. 

OUTCOMES 

Collectively and over time, outputs from hospitals may contribute to changes in outcomes for 

both individuals using inpatient services and for the hospital overall. Examples of potential outcomes within the hospital setting are listed below. 

•	 For the organization 

– Short term (1–2 years) 

> the provision of effective, equitable, understandable, respectful, and quality care 

and services that are responsive to diverse cultural health beliefs and practices, 

preferred languages, health literacy, and other communication needs 

> the use of data on race, ethnicity, sex, sexual orientation, disability status, and 

language to monitor and improve service delivery within the hospital 

133 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE HOSPITAL SETTING 

> improved two-way communication and feedback mechanisms between 

individuals and hospitals 

> racial/ethnic and linguistic concordance between providers, hospital staff, and 

patients 

> increased linkages with community stakeholders, with a focus on social 

determinants of health. 

– Longer term (3 or more years) 

> continued improvement in the provision of high-quality services related to the 

National CLAS Standards 

> better patient outcomes, improved safety, higher-quality care, and a reduction in 

readmission rates 

> reduced hospitalizations for ambulatory-sensitive conditions 

> organizational culture shifts to provide ongoing and visible support for the 

National CLAS Standards within the hospital 

> increased HCAHPS scores (patient experience) 

> increased equity in access to high-quality hospital services and a reduction in 

health disparities. 

• For the individuals seeking care: 

– Short term (1–2 years) 

> individuals have access to high-quality language services 

> individuals are better able to access and navigate hospital services 

> individuals are better able to understand their treatment options and make 

134 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE HOSPITAL SETTING 

informed care decisions 

> patients are better able to understand and follow pre- and post-operative or test 

instructions and discharge plans 

> patients are connected with community resources to facilitate transitions in care. 

– Longer term (3 or more years) 

> greater adherence to medications, treatment protocols, and follow-up after 

discharge 

> more-successful transitions to other care facilities (e.g., home care, long-term 

care, nursing home care) 

> reduced hospital readmission rates and reduced admissions for ambulatorysensitive conditions 

> improved satisfaction among individuals seeking hospital services 

> increased trust in and engagement with the hospital. 

135 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX C: HOSPITAL SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE HOSPITAL SETTING 

QUALITY IMPROVEMENT 

The logic model also depicts the adoption and implementation of the National CLAS Standards 

as a continual process, requiring a QI loop where outputs and outcomes inform the development 

of future hospital actions, policies, or programs to better align with the National CLAS Standards. Culturally competent QI tailors care to address the specific language and culture barriers, 

which both helps to reduce disparities and can improve care for everyone (Green et al., 2010). 

When assessing the impact of the implementation of the National CLAS Standards and informing next steps, it is important that QI improvements be viewed specifically through a culturally 

competent lens. 

136 
APPENDIX C: HOSPITAL SETTING 


HOSPITAL MEASURES
 

In developing the process and outcomes/impact measures described in Chapter Seven of the full report (Davis et al., forthcoming), we identified 

measures relevant to the hospital setting. In Table C.1, we list examples of hospital measures identified along with a brief description, area of 

focus, source, relevant notes, and the reference for each measure. In addition, we include examples of disparity-sensitive measures that a hospital 

might wish to consider to help it assess how well it is doing in addressing identified disparities in outcomes. Table C.2 provides additional detail 

for each measure and summarizes the relevant items that compose each measure. 

TABLE C.1. HOSPITAL MEASURES 

MEASURE DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

Hospital 

Consumer 

Assessment 

of Healthcare 

Providers 

and Systems 

(HCAHPS) 

Survey 

The HCAHPS Survey, also known as the CAHPS Hospital Survey or 

Hospital CAHPS, is a standardized survey instrument and datacollection methodology to measure patients’ perspectives of hospital 

care. The HCAHPS Survey contains 21 patient perspectives on care and 

patient-rating items that encompass nine key topics: communication 

with doctors, communication with nurses, responsiveness of hospital 

staff, pain management, communication about medicines, discharge 

information, cleanliness of the hospital environment, quietness of the 

hospital environment, and transition of care. 

Cultural 

competency 

HCAHPS See Table 

D.2 for list of 

measures. 

AHRQ, 2014. 

137 
APPENDIX C: HOSPITAL SETTING 


HOSPITAL MEASURES
 

MEASURE DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

Hospital 

Consumer 

Assessment 

of Healthcare 

Providers 

and Systems 

(HCAHPS) 

Survey Health 

Literacy Set 

These measures are based on the CAHPS Item Set for Addressing Health 

Literacy, a set of supplemental items for the HCAHPS. The item set 

includes the following domains: information about medications; communication between nurses and patients; communication between doctors 

and patients; communication about tests; communication about forms; 

and information about how to care for yourself at home. 

Health 

literacy 

HCAHPS 

health 

literacy 

See Table 

D.2 for list of 

measures. 

AHRQ, 2012 

Cultural Competency Assessment Tool 

for Hospitals 

(CCATH) 

The CCATH is a survey designed to assess hospitals’ adherence to the 

National CLAS Standards. The CCATH was subject to extensive qualitative 

testing, including pilot testing, focus groups, and cognitive interviews. 

Exploratory and confirmatory factor analysis of the data supported 12 

composite scales: clinical cultural competency practices, human resources 

practices, diversity training, availability of interpreter services, interpreter services policies, quality of interpreter services, translation of written 

materials, leadership and strategic planning, performance management 

systems and QI, data collection on inpatient population, data collection 

on service area, and community representation. 

Cultural 

competency 

CCATH See Table 

D.2 for list of 

measures. 

CCATH 

Overview, 

undated 

The Joint 

Commission 

Hospital 

Accreditation 

Standards and 

Elements of 

Performance 

Joint Commission standards are the basis of an objective evaluation process that can help HCOs measure, assess, and improve performance. The 

standards focus on important patient, individual, or resident care and 

organization functions that are essential to providing safe, high-quality 

care. The Joint Commission’s state-of-the-art standards set expectations 

for organizational performance that are reasonable, achievable, and 

surveyable. The Joint Commission has several accreditation standards that 

directly or indirectly support the provision of culturally and linguistically 

appropriate services. 

CLAS JCAHOa 

accreditation 

standards 

See Table 

D.2 for list of 

measures. 

The Joint 

Commission, 

2014 

138 
APPENDIX C: HOSPITAL SETTING 

HOSPITAL MEASURES 

MEASURE DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

The Joint 

Commission: 

2016 

Accountability 

Measure 

List for 

Accreditation 

ChartAbstracted 

Process 

Measures 

The Joint Commission categorizes its process performance measures into 

accountability and nonaccountability measures. This approach places 

more emphasis on an organization’s performance on accountability 

measures—quality measures that meet four criteria designed to identify 

measures that produce the greatest positive impact on patient outcomes 

when hospitals demonstrate improvement: research, proximity, accuracy, 

and adverse effects. Measures that meet all four criteria should be used 

for purposes of accountability (e.g., for accreditation, public reporting, or 

pay-for-performance). Those measures that have not been designated as 

accountability measures may be useful for QI, exploration, and learning 

within individual HCOs and are good measures in terms of gauging appropriate patient care. The accountability measures cover areas including 

inpatient psychiatric services, venous thromboembolism (VTE) care, stroke 

care, perinatal car, immunization, tobacco treatment, and substance use. 

Accountability 

JCAHOa 

accountability 

measures 

See Table 

D.2 for list of 

measures. 

The Joint 

Commission, 

2016 

Disparity-sensitive measures or CLAS-salient measures 

Hospital 

30-day, allcause RSRR 

following 

pneumonia 

hospitalization 

The measure estimates a hospital-level 30-day, all-cause RSRR for patients 

discharged from the hospital with either a principal discharge diagnosis 

of pneumonia, including aspiration pneumonia or a principal discharge 

diagnosis of sepsis (not severe sepsis) with a secondary diagnosis of 

pneumonia (including aspiration pneumonia) coded as present on 

admission (POA). Readmission is defined as unplanned readmission for 

any cause within 30 days of the discharge date for the index admission. 

A specified set of planned readmissions do not count as readmissions. 

CMS annually reports the measure for patients who are 65 years or older 

and are enrolled in FFS Medicare hospitalized in nonfederal hospitals. 

Patient 

safety, care 

coordination 

NQF #506, 

#505, 

#695, 

#1891, 

#2515, 

#1551 

(measure 

steward: 

CMS) 

Also available 

for AMI, PCI, 

COPD, HF, 

CABG, 

THA/TKA 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: 

“506,” 

“505,” 

”695,” 

”1891,” 

”2515,” or 

”1551”) 

Weissman et 

al., 2012 

139 
 

 

APPENDIX C: HOSPITAL SETTING 


HOSPITAL MEASURES 

MEASURE DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

Median time 

to electrocardiogram 

(ECG) 

Median time from emergency department arrival to ECG (performed 

in the emergency department prior to transfer) for AMI or chest pain 

patients (with probable cardiac chest pain) 

Prevention 

and 

treatment 

NQF #289 

(measure 

steward: 

CMS) 

NQF, 

undated 

(search: 

“289”) 

Hospital 

30-day, allcause, RSMR 

following 

CABG surgery 

The measure estimates a hospital-level RSMR for patients ages 18 and 

older discharged from the hospital following a qualifying isolated CABG 

procedure. Mortality is defined as death from any cause within 30 days 

of the procedure date of an index CABG admission. The measure was 

developed using Medicare FFS patients ages 65 and older and was tested 

in all-payer patients ages 18 and older. An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the 

mortality outcome. 

Patient 

safety, care 

coordination 

NQF 

#2558, 

#230, 

#1893, 

#229, #468 

(measure 

steward: 

CMS) 

Also available 

for AMI, 

COPD, HF, 

pneumonia 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: 

“2558,” 

“230,” 

“1893,” 

“229,” or 

“468”) 

Weissman et 

al., 2012 

Riskadjusted 

deep sternal 

wound 

infection 

Percentage of patients ages 18 and older undergoing isolated CABG who 

develop mediastinitis or deep sternal wound infection within 30 days 

postoperatively 

Prevention 

and 

treatment, 

safety 

NQF #130 

(measure 

steward: 

Society of 

Thoracic 

Surgeons) 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: 

“130”) 

Weissman et 

al., 2012 

NOTE: PCI = percutaneous coronary intervention. CABG = coronary artery bypass grafting. COPD = chronic obstructive pulmonary disease. 


HF = heart failure. THA/TKA = total hip arthroplasty/total knee arthroplasty.
 

a

 The Joint Commission on Accreditation of Healthcare Organizations is now known as the Joint Commission. 


140 
APPENDIX C: HOSPITAL SETTING 


HOSPITAL MEASURES 

TABLE C.2. HOSPITAL MEASURES: ADDITIONAL DETAIL 

MEASURE ITEMS 

HCAHPS Survey The HCAHPS Survey, also known as the CAHPS Hospital Survey or Hospital CAHPS, is a standardized survey instrument and 

data-collection methodology to measure patients’ perspectives of hospital care. 

The HCAHPS Survey contains 21 patient perspectives on care and patient rating items that encompass nine key 

topics: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, 

communication about medicines, discharge information, cleanliness of the hospital environment, quietness of the hospital 

environment, and transition of care. 

Nurse 

communication 

During this hospital stay, how often did nurses treat you with courtesy and respect? 

During this hospital stay, how often did nurses listen carefully to you? 

During this hospital stay, how often did nurses explain things in a way you could understand? 

Doctor 

communication 

During this hospital stay, how often did doctors treat you with courtesy and respect? 

During this hospital stay, how often did doctors listen carefully to you? 

During this hospital stay, how often did doctors explain things in a way you could understand? 

Communication 

about medicines 

Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? 

Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could 

understand? 

Discharge 

information 

After you left the hospital, did you go directly to your own home, to someone else’s home, or to another health facility? 

During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help 

you needed when you left the hospital? 

During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after 

you left the hospital? 

Care transition During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my 

health care needs would be when I left. 

When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. 

When I left the hospital, I clearly understood the purpose for taking each of my medications. 

141 
APPENDIX C: HOSPITAL SETTING 

HOSPITAL MEASURES 

MEASURE ITEMS 

HCAHPS Survey 

Health Literacy Set 

These measures are based on the CAHPS Item Set for Addressing Health Literacy, a set of supplemental items for the 

HCAHPS. The item set includes the following domains: information about medications; communication between nurses 

and patients; communication between doctors and patients; communication about tests; communication about forms; 

information about how to care for yourself at home. 

Information about 

medications 

H-HL1: Staff asked patient to describe how patient would take medications at home 

H-HL2: Staff told patient who to call if patient had questions about medications 

Communication 

between nurses 

and patients 

H-HL3: Nurses were hard to understand because of the way they spoke patient’s language 

H-HL4: Nurses used medical words patient did not understand 

H-HL5: Nurses spoke too fast 

H-HL6: Nurses interrupted patient 

H-HL7: Nurses answered all questions to patient’s satisfaction 

H-HL8: Nurses used condescending, sarcastic, or rude tone or manner with patient 

H-HL9: Nurses cared about patient as a person 

Communication 

between doctors 

and patients 

H-HL10: Doctors were hard to understand because of the way they spoke patient’s language 

H-HL11: Doctors used medical words patient did not understand 

H-HL12: Doctors spoke too fast 

H-HL13: Doctors used pictures, drawings, models, or videos to explain things 

H-HL14: Doctors interrupted patient 

H-HL15: Doctors answered all questions to patient’s satisfaction 

H-HL16: Doctors made sure patient understood all information 

H-HL17: Doctors used condescending, sarcastic, or rude tone or manner with patient 

H-HL18: Doctors cared about patient as a person 

142 
APPENDIX C: HOSPITAL SETTING 

HOSPITAL MEASURES 

MEASURE ITEMS 

Communication 

about tests 

(Note: H-HL20 

through H-HL23 

form a composite 

measure: how 

well hospital staff 

explain tests and 

test results) 

H-HL19: Patient had a blood test, X-ray, or other test 

H-HL20: Hospital staff explained what a blood test, X-ray, or other test was for 

H-HL21: Explanation of blood test, X-ray, or other test was easy to understand 

H-HL22: Hospital staff explained blood test, X-ray, or other test results to patient 

H-HL23: Blood test, X-ray, or other test results were easy to understand 

Communication 

about forms 

(Note: H-HL25, 

H-HL27, H-HL28 

and H-HL29 form 

a composite 

measure: ease of 

filling out forms) 

H-HL24: Patient had to sign forms 

H-HL25: Staff explained the purpose of a form before patient signed it 

H-HL26: Patient had to fill out forms 

H-HL27: Staff offered patient help in filling out a form 

H-HL28: Forms were easy for patient to fill out 

H-HL29: Patient was given enough time to fill out forms 

H-HL30: Patient needed forms in a language other than English 

H-HL31: Forms were available in patient’s language 

Information about 

how to care for 

yourself at home 

H-HL32: Patient went to own home, someone else’s home, or another health facility 

H-HL33: Staff give patient a telephone number to call if patient had problems after leaving hospital 

H-HL34: Staff told patient how to take care of self at home 

H-HL35: Information from hospital staff about taking care of self at home was easy to understand 

H-HL36: Patient received instructions in writing about how to take care of self at home 

H-HL37: Written instructions about how to take care of self at home were easy to understand 

H-HL38: Patient needed instructions about how to take care of self at home in a language other than English 

H-HL39: Instructions about how to take care of self at home were available in patient’s language 

143 
APPENDIX C: HOSPITAL SETTING 

HOSPITAL MEASURES 

MEASURE	 ITEMS 

CCATH	 The CCATH is a survey designed to assess hospitals’ adherence to the CLAS Standards. The CCATH was subject to extensive 

qualitative testing, including pilot testing, focus groups, and cognitive interviews. Exploratory and confirmatory factor 

analysis of the data supported 12 composite scales: clinical cultural competency practices, human resources practices, 

diversity training, availability of interpreter services, interpreter services policies, quality of interpreter services, translation 

of written materials, leadership and strategic planning, performance management systems and QI, data collection on 

inpatient population, data collection on service area, and community representation. 

Clinical cultural 

competency 

practices 

Does the hospital consider cultural and language needs during discharge planning? 

Does the hospital accommodate the ethnic/cultural dietary preferences of inpatients? 

Does the hospital tailor patient educational materials for different cultural and language groups? 

Does the hospital tailor patient clinical assessments for different cultural and language groups? 

Human resources 

practices 

Which of the following benefits are available to staff? 

• Formal mentoring program 

• Management training 

• Tuition assistance or tuition reimbursement for ongoing education 

• Personal counseling or employee assistance programs 

• Flexible benefits, such as domestic partner benefits, family illness, death, and personal leave policies that 

accommodate alternative definitions of family 

• Affinity (networking) groups for racial/ethnic minority staff 

• Work/life balance programs, such as flex time, job-sharing or telecommuting, child or elder care 

Diversity training	 Does this hospital have a formal and ongoing training program on cultural and language diversity? 

Does the staff involved in the formal complaint and grievance process receive formal training in conflict resolution? 

Does the staff involved in the formal complaint and grievance process receive formal training about cultural or language 

differences? 

144 
APPENDIX C: HOSPITAL SETTING 

HOSPITAL MEASURES 

MEASURE	 ITEMS 

Availability of	 

interpreter services	

Are interpreter services available for inpatients in Spanish? 

Are interpreter services available for inpatients in Chinese? 

Are interpreter services available for inpatients in Vietnamese? 

Are interpreter services available for inpatients in Korean? 

Are interpreter services available for inpatients in Tagalog? 

Interpreter services	

policies	 

Does this hospital have a written policy and procedures about the use of bilingual staff as interpreters? 

Does this hospital have a written policy and procedures about the use of face-to-face professional interpreters? 

Does this hospital have a written policy and procedures about the use of face-to-face volunteer interpreters? 

Does this hospital have a written policy and procedures about the use of family or friends as interpreters? 

Quality of	 

interpreter services

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? 

Does the hospital require an assessment of interpreter fluency in translating medical terms and procedures? 

Does the hospital require an assessment of interpreter accuracy and completeness? 

Translation of 

written materials 

What types of written materials does this hospital routinely provide to inpatients in languages other than English? 

• Informed consent statements? 

• Medication instructions? 

• Discharge planning instructions? 

• Patient advance directives? 

• Health education material? 

• Does this hospital post signs providing directions in languages other than English? 

145 
APPENDIX C: HOSPITAL SETTING 

HOSPITAL MEASURES 

MEASURE ITEMS 

Leadership and 

strategic planning 

Does this hospital’s statement of strategic goals include specific language about recruitment of a culturally diverse 

workforce? 

Does this hospital’s statement of strategic goals include specific language about retention of a culturally diverse workforce? 

Does this hospital’s statement of strategic goals include specific language about the provision of culturally appropriate 

patient services? 

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

Is there a person, office, or committee who has dedicated responsibility for promoting this hospital’s cultural diversity 

goals? 

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? 

Performance 

management 

systems and QI 

Does the employee satisfaction survey include measures of diversity climate?
 

Is the following assessment conducted at least once each year:
 

• Accessibility of interpreter services?
 

• Racial/ethnic differences in inpatient service use? 

Data collection 

on inpatient 

population 

Does this hospital collect any ethnicity or racial data on individuals receiving inpatient services? 

Does this hospital collect data on the preferred language for individuals receiving inpatient services? 

Data collection on 

service area 

Does this hospital track changes in the race or ethnicity of its workforce? 

Does this hospital collect or receive any of the following data on the population residing in the service area? 

• Race/ethnicity 

• Languages spoken 

• Income levels 

• Education levels 

• Health risk profiles (for diseases or conditions that disproportionately affect a particular racial/ethnic/gender group, 

such as African-American men, Latino women, or individuals of Jewish ethnicity) 

• Using health screening services (mammograms, prostate screening exams, Pap smears) 

146 
APPENDIX C: HOSPITAL SETTING 

HOSPITAL MEASURES 

MEASURE ITEMS 

Community 

representation 

Are community representatives routinely involved in the planning and design of inpatient services for culturally diverse 

populations? 

Are community representatives routinely involved in the evaluation of existing services for culturally diverse populations? 

The Joint 

Commission Hospital 

Accreditation 

Standards and 

Elements of 

Performance 

Joint Commission standards are the basis of an objective evaluation process that can help HCOs measure, assess, and 

improve performance. The standards focus on important patient, individual, or resident care and organizational functions 

that are essential to providing safe, high-quality care. The Joint Commission’s state-of-the-art standards set expectations 

for organizational performance that are reasonable, achievable, and surveyable. The Joint Commission has several 

accreditation standards that directly or indirectly support the provision of culturally and linguistically appropriate services. 

Here we highlight standards that support CLAS Standard 10. 

The hospital 

compiles and 

analyzes data 

(PI.02.01.01) 

Element of Performance (EP) 4: The hospital analyzes and compares internal data over time to identify levels of 

performance, patterns, trends, and variations. 

The hospital 

improves 

performance on 

an ongoing basis 

(PI.03.01.01) 

EP 11: For hospitals that elect the Joint Commission Primary Care Medical Home option: The primary care medical home 

uses the data it collects on the patient’s perception of the safety and quality of care, treatment, or services to improve its 

performance. These data include the following: 

• Patient experience and satisfaction related to access to care, treatment, or services and communication 

• Patient perception of the comprehensiveness of care, treatment, or services 

• Patient perception of the coordination of care, treatment, or services 

• Patient perception of the continuity of care, treatment, or services 

147 
APPENDIX C: HOSPITAL SETTING 

HOSPITAL MEASURES 

MEASURE ITEMS 

The Joint 

Commission: 2016 

Accountability 

Measure List for 

Accreditation ChartAbstracted Process 

Measures 

The Joint Commission categorizes its process performance measures into accountability and nonaccountability measures. 

This approach places more emphasis on an organization’s performance on accountability measures—quality measures 

that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes 

when hospitals demonstrate improvement: research, proximity, accuracy, and adverse effects. Measures that meet all four 

criteria should be used for purposes of accountability (e.g., for accreditation, public reporting, or pay-for-performance). 

Those measures that have not been designated as accountability measures may be useful for QI, exploration, and learning 

within individual HCOs, and are good advice in terms of appropriate patient care. The accountability measures cover areas 

including inpatient psychiatric services, VTE care, stroke care, perinatal car, immunization, tobacco treatment, and substance 

use. Here we highlight measures in VTE care and substance use. 

VTE care VTE-5 warfarin therapy discharge instructions 

Immunization IMM-2 16253 Influenza immunization 

Substance use SUB-1 16350 Alcohol use screening 

SUB-2 16351 Alcohol use brief intervention provided or offered 

2014 SUB-3 16353 Alcohol and other drug use disorder treatment provided or offered at discharge 

2014 SUB-4 16355 Alcohol and drug use: assessing status after discharge 

148 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Appendix D 

Public Health Setting
 

The field of public health encompasses local health departments, local boards of health, tribal 

health departments, and other local government organizations that are responsible for providing 

essential public health services within a specific jurisdiction (CDC, 2017b). Together, these agencies 

are often referred to as local health departments (LHDs). LHDs play a critical role in monitoring 

community health, informing and educating the public about health, mobilizing community partnerships, and developing policies and plans that support individual and community health efforts 

(CDC, 2016a). In particular, there are three core functions of public health around which LHDs often 

organize their work (CDC, 2017b): 

1.	 linking people to needed personal health services and ensuring the provision of health care 

when otherwise unavailable 

2.	 ensuring a competent public and personal health care workforce 

3.	 evaluating the effectiveness, accessibility, and quality of personal and population-based 

health services. 

The National CLAS Standards are in alignment with and have the potential to further strengthen 

each of these core functions (see Table D.1). Given their focus on population health, LHDs serve 

individuals from a variety of cultural and linguistic backgrounds. As a result, the National CLAS 

Standards are particularly relevant to LHDs. 

149 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX D: PUBLIC HEALTH SETTING 


FIGURE D.1. LINKING THE NATIONAL CLAS STANDARDS TO CORE PUBLIC HEALTH DEPARTMENT 

FUNCTIONS 

CORE PUBLIC HEALTH DEPARTMENT 

FUNCTION 

ROLE OF THE NATIONAL CLAS STANDARDS 

Linking people to needed personal health 

services and ensuring the provision of health 

care when otherwise unavailable 

Ensure that the provision of health care— 

provided by LHDs or organizations partnering 

with LHDs—is culturally and linguistically 

appropriate 

Ensuring a competent public and personal	 

health care workforce	 

Ensure workforce competencies, including 

cross-cultural communication skills and the 

ability to communicate (alone or through 

a translator) in ways that individuals can 

understand 

Evaluating the effectiveness, accessibility, and 

quality of personal and population-based 

health services 

Ensure data collection, including data on 

cultural subgroups—such as race/ethnicity, 

language preferences, education, and income 

of patients—to ensure evaluations capture 

cultural and linguistic differences 

Despite the natural alignment between the National CLAS Standards, the core functions of public health, and the populations LHDs commonly serve, the acceptance of the Standards by LHD 

leadership differs across jurisdictions. These differences may be based on a range of characteristics 

unique to each LHD and the perceived needs of the population served (see Table D.2). For example, LHDs often already include professionals who reflect the populations they serve. This means 

that they may have critical cultural and language competencies and they may be more sensitive to 

the diversity of the populations they serve. Training on cultural and linguistic appropriateness of 

care is increasingly offered as part of formal public health schooling, embedded in existing pub150 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX D: PUBLIC HEALTH SETTING 


lic health staff training, and required by some states (e.g., Maryland). As a result, LHDs may have 

different perceptions of the added value of the National CLAS Standards relative to their current 

standards of practice. 

FIGURE D.1. LINKING THE NATIONAL CLAS STANDARDS TO CORE PUBLIC HEALTH DEPARTMENT 

FUNCTIONS 

CHARACTERISTIC DETAILS 

Geographic reach LHDs can serve communities at the local, state, tribal, and/or regional 

level. Some states have no local public health agencies and rely on LHDs 

with larger catchment areas. 

Size of population 

served 

The size of the population served varies considerably, with 43 percent 

of LHDs serving populations of 25,000 or less and 5 percent serving 

populations of 500,000 or more. 

Relationship 

between state, 

tribal, and LHD 

Services offered can be centralized, decentralized, or hybrid; centralized 

services are provided by a state health department and are coordinated 

by local offices, while decentralized services are planned and provided by 

local agencies. 

Type of jurisdiction The type of jurisdiction varies considerably and can include county, 

city/county, township, multi-county/district/regional, city, and tribal 

communities. 

Governance A board of health may serve in a policymaking capacity or an advisory 

capacity only. 

Funding sources The combination of funding sources varies by LHD and may include local 

contributions, state contributions, federal pass-through funding, Medicaid 

and Medicare reimbursements, and fees. 

Size of staff, budget, 

type of health care 

services provided 

Varies considerably 

151 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX D: PUBLIC HEALTH SETTING 

LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE PUBLIC HEALTH SETTING 

Figure D.1 provides a detailed logic model of the specific inputs, activities, outputs, and outcomes 

for the implementation of the National CLAS Standards within the public health setting. Given 

the importance of the broader context and external resources and partnerships to shape a public 

health setting’s readiness for adopting the National CLAS Standards, we include them in the context, antecedents, and inputs section. Any changes should be made in partnership with the community and other stakeholders. 

CONTEXT, ANTECEDENTS, AND INPUTS 

Linkages with the Community and Other Stakeholders 

Successful implementation of the National CLAS Standards requires clear and meaningful linkages between LHDs, the community, and relevant stakeholder groups in every step of the process 

to understand and address the cultural and linguistic needs of the communities served (Wilson-Stronks and Galvez, 2007; Weech-Maldonado and Merrill, 2000). LHDs are increasingly focused on developing partnerships with community and faith-based organizations (CFBOs) to mitigate the negative consequences of economic changes on their budgets and to leverage greater 

assets in community health promotion. Partnerships between LHDs and CFBOs likely increase the 

capacity of LHDs to provide public health services (Wholey, Gregg, and Moscovice, 2009) and can 

expand the reach of LHD activities into communities that are marginalized because of cultural 

divisions and a lack of resources. CFBOs are a critical component to public health systems (Mays, 

Halverson, and Scutchfield, 2003). They often have the capabilities needed to provide public 

health interventions and are trusted resources in their communities (Acosta et al., 2011). CFBOs 

share an interest in population health and well-being and can bring community knowledge to 

152 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX D: PUBLIC HEALTH SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE PUBLIC HEALTH SETTING 

the table, improve trust in governmental public health, and make the work of public 

health more transparent and understandable. The development of partnerships and coalitions has been evident in most public health program areas, such as maternal and child 

health, HIV/AIDS, and chronic disease prevention. 

In this section we focus on the role of LHDs in implementing the National CLAS 

Standards and in coordinating with a range of stakeholders. Some LHDs provide direct 

services (e.g., immunizations, screenings, treatment for tuberculosis and sexually 

transmitted diseases) at public health centers and through community clinics. LHDs 

may also provide inpatient care through public hospitals. In other places, they do not 

provide services directly, instead developing formal and informal partnerships to provide 

care for the most vulnerable. The most formal of these partnerships are contracts to 

provide services. In these cases, the National CLAS Standards are relevant both to the 

LHD and to its community partners. In health care, these partners include ambulatory 

care clinics that may screen for infectious diseases and provide vaccinations. As a result, 

LHDs must consider how they work with partners and contracted organizations to 

implement the Standards because this will influence their performance with respect 

to meeting the cultural and linguistic needs of the individuals they serve. Primary care 

and inpatient providers are also obligated to report certain conditions to LHDs. For 

example, in California, providers must report a large number of communicable diseases, 

HIV, outbreaks of any condition or disease, the occurrence of any unusual disease, 

and some noncommunicable conditions or diseases (California Department of Public 

Health, 2016). Other entities provide substance abuse treatment, maternal and child 

health services, environmental health services, and communicable/infections disease 

153 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

APPENDIX D: PUBLIC HEALTH SETTING 


LOGIC MODEL FOR IMPLEMENTATION OF THE NATIONAL CLAS STANDARDS WITHIN 

THE PUBLIC HEALTH SETTING 

and chronic disease programs (National Association of County and City Health Officials 

[NACCHO], 2014). LHDs engage many different partners inside and outside the health 

care system, including schools, media, local businesses, faith-based organizations, and 

other community-based organizations (NACCHO, 2009). 

LHDs’ links to outside partners provide opportunities for formal and informal 

dissemination of the National CLAS Standards. There are several mechanisms through 

which this might occur. LHDs are part of a rich network of organizations in the 

community that are aligned toward the same population health goals, including 

health care clinics and mental health and substance abuse treatment centers, as well as 

organizations that provide specialty services to persons with specific conditions, such as 

HIV. Dissemination of the National CLAS Standards within public health organizations 

could increase the likelihood that these Standards are adopted by other organizations. 

LHDs sometimes have more-formal relationships with these organizations through 

memoranda of understanding and funding mechanisms. LHDs could thus exert 

financial pressure on partners to adopt the National CLAS Standards. In addition, LHDs 

could support the adoption of the National CLAS Standards within the community by 

disseminating toolkits and collecting and analyzing data that evaluate the impact of the 

Standards in their communities. 

154 
APPENDIX D: PUBLIC HEALTH SETTING 


PUBLIC HEALTH MEASURES
 

In developing the process and outcomes/impact measures described in Chapter Seven of the main report (Davis et al., forthcoming), we identified 

measures relevant to public health settings. In Table D.1 we list examples of relevant measures identified along with a brief description, area of 

focus, source, relevant notes, and the reference for each measure. In addition, we include examples of disparity sensitive measures that a public 

health organization might wish to consider to help it assess how well it is doing in addressing identified disparities in outcomes. Table D.2 provides additional detail for each measure and summarizes the relevant items that compose each measure. 

TABLE D.1. PUBLIC HEALTH MEASURES 

MEASURE(S) DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

Developing 

a SelfAssessment 

Tool for 

CLAS in Local 

Public Health 

Agencies 

(LPHAs) 

This self-assessment tool for LPHAs is aimed to offer sound measures of 

CLAS. The term LPHA is defined as a publicly funded entity (i.e., local 

health department, local board of health, and other local government 

organization) responsible for providing essential public health services 

within a specific jurisdiction. The instrument consists of a director or 

designee interview protocol; a staffing questionnaire; and a client 

services questionnaire. Because the content among the three survey instruments greatly overlap, not all items from each instrument are presented in this document. Listed in the appendix of COSMOS Corporation (2003) are items from the Client Services Questionnaire (consisting 

of four sections: quality monitoring and improvement, management 

information systems, translation and interpretation services, and other 

related client services and benefits), and select items from the director 

or designee interview protocol. 

CLAS 

Services 

Developing 

a SelfAssessment 

Tool for 

Culturally and 

Linguistically 

Appropriate 

Services in 

Local Public 

Health 

Agencies 

Though a pilot 

test has been 

conducted 

on the selfassessment 

tools, 

measures 

have yet to 

be tested/ 

validated. 

See Table 

F.2 for list of 

measures 

COSMOS 

Corporation, 

2003 

155 
APPENDIX D: PUBLIC HEALTH SETTING 


PUBLIC HEALTH MEASURES
 

MEASURE(S) DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

CG-CAHPS CAHPS surveys ask consumers and patients to report on and evaluate 

their experiences with health care. The CG-CAHPS assesses patients’ 

experiences with health care providers and staff in doctors’ offices. 

The CG-CAHPS produces the following measures of patient experience: 

getting timely appointments, care, and information; how well 

providers communicate with patients; providers’ use of information to 

coordinate patient care; helpful, courteous, and respectful office staff; 

patients’ rating of the provider. 

Patient 

experience 

CG-CAHPS See Table F.2 

for list of measures. 

AHRQ, 

2013b 

Disparity-sensitive measures or CLAS-salient measures 

Flu vaccinations for 

adults ages 

18 and older 

The percentage of adults ages 18 and older who self-report receiving 

an influenza vaccine within the measurement period. This measure 

collected via the CAHPS 5.0H adults survey for Medicare, Medicaid, 

commercial populations. It is reported as two separate rates stratified 

by age: 18–64 and 65 years of age and older. 

Health and 

well-being 

NQF #39 

(measure 

steward: 

NCQA) 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: 

“39”) 

NQF, 2012g 

Asthma 

emergency 

department 

visits 

Percentage of patients with asthma who have one or more visits to the 

emergency room for asthma during the measurement period. 

Chronic care 

management 

NQF #1381 

(measure 

steward: 

Alabama 

Medicaid 

Agency) 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: 

“1381”) 

NQF, 2012g 

156 
APPENDIX D: PUBLIC HEALTH SETTING 


PUBLIC HEALTH MEASURES
 

MEASURE(S) DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

Depression 

screening by 

18 years of 

age 

The percentage of adolescents 18 years of age who had a screening for 

depression using a standardized tool. 

Health and 

well-being 

NQF #1515 

(measure 

steward: 

NCQA) 

This is a 

disparitysensitive 

measure. 

NQF, 

undated 

(search: 

“1515”) 

NQF, 2012g 

Preventive 

care and 

screening: 

tobacco use: 

screening 

and 

cessation 

intervention 

Percentage of patients ages 18 and older who were screened for 

tobacco use one or more times within 24 months AND who received 

cessation counseling intervention if identified as a tobacco user. 

Community/ 

population 

health 

NQF #28 

(measure 

steward: 

American 

Medical 

Association– 

convened 

Physician 

Consortium 

for 

Performance 

Improvement) 

NQF, 

undated 

(search: 

“28”) 

157 
APPENDIX D: PUBLIC HEALTH SETTING 


PUBLIC HEALTH MEASURES 

TABLE D.2. PUBLIC HEALTH MEASURES: ADDITIONAL DETAIL 

MEASURES ITEMS
 

Developing a selfassessment tool for 

CLAS in LPHAs 

This self-assessment tool for LPHAs is aimed to offer sound measures of CLAS. The term LPHA is defined as a publicly 

funded entity (i.e., local health department, local board of health, and other local government organization) responsible 

for providing essential public health services within a specific jurisdiction. The instrument consists of a director or designee 

interview protocol; a staffing questionnaire; and a Client Services Questionnaire. Because the content among the three 

survey instruments greatly overlap, not all items from each instrument are presented in this document. Listed in the 

appendix of COSMOS Corporation (2003) are items from the Client Services Questionnaire (consisting of four sections: 

quality monitoring and improvement, management information systems, translation and interpretation services, and other 

related client services and benefits), and select items from the director or designee interview protocol. Refer to the cited 

report for complete instruments, including survey questions and multiple-choice items (COSMOS Corporation, 2003). 

Director or 

designee 

telephone 

interview protocol 

(selected items) 

2. Does your local board of health or other governing body have a subcommittee or other group responsible for issues
 

involving services provided to racial, ethnic, and linguistic minority groups?
 

3. Does your agency use community advisory boards or other similar entities to address community and client issues
 

specifically related to the cultural and linguistic groups (represented by your clients)?
 

5. Does your agency conduct periodic needs assessments of community and/or clients’ needs?
 

5a. Do these assessments include a component that specifically measures the need for culturally and linguistically
 

appropriate services?
 

6a. Does your agency’s plan include a component that improves the quality of services provided specifically to culturally and
 

linguistically diverse clients?
 

7. Which of the following activities does your agency use to monitor the quality of culturally and linguistically appropriate
 

services?
 

8. Is there a position in your agency specifically designated to promote and coordinate culturally and linguistically
 

appropriate services?
 

9. Does your agency have a written policy governing language translation of written information for your clients?
 

11. Does your agency have a written policy governing interpretation services and assistance for your clients?
 

158 
APPENDIX D: PUBLIC HEALTH SETTING 

PUBLIC HEALTH MEASURES 

MEASURES ITEMS 

Client services 

questionnaire: 

quality monitoring 

and improvement 

12. Does your agency’s client information database record race and ethnicity? 

13. Please report or estimate what percentage of your clients falls into the following racial groups. 

14. Please report or estimate what percentage of your clients falls into the following ethnic groups. 

15. Does your agency’s client information database record the primary language spoken by each client? 

16. Approximately what percentage of your clients speaks a primary language other than English? 

17. In your agency’s data systems, can client demographic information (such as race/ethnicity and language) be linked with 

other data (such as client satisfaction, grievances/complaints, and dis-enrollment)? 

Client services 

questionnaire: 

translation and 

interpretation 

services 

18. Which of the following types of written materials are available to your clients in one or more languages other than 

English? 

19. Which of the following activities are used to develop written materials in languages other than English? 

20. Which of the following practices generally apply to the translations of written materials provided by your agency to its 

clients? 

21. Which of the following entities provide review and/or approval of translated materials and products available to your 

clients? 

22. Does your agency set and monitor targets or threshold levels for which vital documents and other written materials are 

translated to meet the language needs of your clients? 

23. What methods are used by your agency to determine the need for translation of written materials into languages 

spoken by your clients? 

24. Which of the following sources are used to determine the languages spoken by the populations served by your agency? 

25. Which of the following methods are used to inform clients of the availability of translated documents and materials? 

26. Is there a specific budget line in your agency for the allocation of funds to support translation of written documents 

and materials into languages spoken by your clients? 

27. Which of the following interpretation services are available to your clients? 

28. Which of the following characteristics apply to the language interpreters used by your agency? 

29. Which of the following entities review and/or approve staffing and operation of interpretation services available to 

your clients? 

30. Does your agency set and monitor targets or threshold levels for which interpretation services are systematically made 

available to meet the language needs of your clients? 

159 
APPENDIX D: PUBLIC HEALTH SETTING 

PUBLIC HEALTH MEASURES 

MEASURES	 ITEMS 

31. What methods are used by your agency to determine the need for interpretation services? 

32. Please provide the best estimate of how many employed, contracted, and certified medical interpreters are available to 

provide language assistance to your clients and staff? 

33. At which of the following key entry or contact points does your agency provide interpretation services in languages 

other than English spoken by your clients? 

34. Which of the following methods are used to inform clients of the availability of bilingual speakers and interpretation 

services in your agency? 

35. Is there a specific budget line for the allocation of funds to support bilingual speakers and interpretation services in 

your agency? 

36. For which of the following groups are translated materials and interpretation services generally made available by your 

agency? 

Client services 

questionnaire: 

other related client 

services 

37. Which of the following are provided or assured by your agency in an effort to be more culturally responsive to your 

clients? (Mark all that apply.) 

38. Which of the following complementary or alternative healing practices are offered to your clients? (Mark all that apply.) 

39. Which of the following kinds of information are available to your clients to promote the ability of your employed staff, 

contractors, and/or partnership members to serve culturally and linguistically diverse groups? (Mark all that apply.) 

40. Which of the following characteristics pertain to written materials available to your clients? (Mark all that apply.) 

41. Which of the following benefits have been achieved by your agency as a result of providing or assuring services that are 

responsive to the cultural and linguistic diversity of your clients? (Mark all that apply.) 

42. Which of the following factors present challenges for your agency in providing or assuring services that are responsive 

to the needs of culturally and linguistically diverse clients? (Mark all that apply.) 

CG-CAHPS Survey	 CAHPS Surveys ask consumers and patients to report on and evaluate their experiences with health care. The CG-CAHPS 

assesses patients’ experiences with health care providers and staff in doctors’ offices. The CG-CAHPS produces the following 

measures of patient experience: getting timely appointments, care, and information; how well providers communicate with 

patients; providers’ use of information to coordinate patient care; helpful, courteous, and respectful office staff; patients’ 

rating of the provider. 

160 
APPENDIX D: PUBLIC HEALTH SETTING 

PUBLIC HEALTH MEASURES 

MEASURES ITEMS 

Getting timely 

appointments, 

care, and 

information 

• Patient got appointment for urgent care as soon as needed. 

• Patient got appointment for non-urgent care as soon as needed. 

• Patient got answer to medical question the same day he/she contacted provider’s office. 

How well providers 

communicate with 

patients 

• Provider explained things in a way that was easy to understand. 

• Provider listened carefully to patient. 

• Provider showed respect for what patient had to say. 

• Provider spent enough time with patient. 

161 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Appendix E 

Cross-Cutting Measures
 

When we developed the process and outcomes/impact measures described in Chapter Seven of 

the full report (Davis et al., forthcoming), we also identified measures that are relevant to more 

than one setting and refer to them as cross-cutting. In Table E.1, we list the six cross-cutting 

measures identified, along with a brief description, area of focus, source, the settings the measure 

is applicable to, and the reference for each measure. Table E.2 provides additional detail for each 

measure and lists the items that compose each measure. 

162 
APPENDIX E: CROSS-CUTTING MEASURES
 

TABLE E.1. CROSS-CUTTING MEASURES 

MEASURE(S) DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

Clinician/ 

group’s 

cultural 

competence 

based on 

the CAHPS 

Cultural 

Competence 

Item Set 

These measures are based on the CAHPS Cultural Competence 

Item Set, a set of supplemental items for the CG-CAHPS that 

includes the following domains: patient-provider communication; complementary and alternative medicine; experiences of 

discrimination because of race/ethnicity, insurance, or language; 

experiences leading to trust or distrust, including level of trust, 

caring, and confidence in the truthfulness of their provider; and 

linguistic competency (access to language services). Samples for 

the survey are drawn from adults who have at least one provider visit within the past year. Measures can be calculated at the 

individual clinician level or at the group (e.g., practice, clinic) 

level. 

Cultural 

competency 

NQF #1904— 

Clinician/ 

group’s cultural 

competence 

based on the 

CAHPS Cultural 

Competence Item 

Set (AHRQ) 

Applicable to 

ambulatory 

care, hospital, 

and behavioral 

health settings. 

See Appendix 

C for list of measures. 

NQF, 2012c 

NQF, 2012f 

Clinician/ 

groups’ 

health 

literacy 

practices 

based on 

the CAHPS 

Item Set for 

Addressing 

Health 

Literacy 

These measures are based on the CAHPS Item Set for Addressing 

Health Literacy, a set of supplemental items for the CG-CAHPS. 

The item set includes the following domains: communication 

with provider (doctor), disease self-management, communication about medicines, communication about test results, and 

communication about forms. Samples for the survey are drawn 

from adults who have had at least one provider visit within the 

past year. Measures can be calculated at the individual clinician 

level or at the group (e.g., practice, clinic) level. 

Health 

literacy 

NQF #1902— 

Clinician/groups’ 

health literacy 

practices based on 

the CAHPS Item 

Set for Addressing 

Health Literacy 

(AHRQ) 

Applicable to 

ambulatory 

care, hospital, 

and behavioral 

health settings. 

NQF, 2012d 

NQF, 2012f 

163 
APPENDIX E: CROSS-CUTTING MEASURES 

MEASURE(S) DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

Patients 

receiving 

language 

services 

supported 

by qualified 

language 

services 

providers 

This measure is used to assess the percentage of patients 

with LEP receiving both initial assessment and discharge 

instructions from assessed and trained interpreters or from 

bilingual providers and bilingual workers/employees assessed 

for language proficiency. The measure provides information on 

the extent to which language services are provided by trained 

and assessed interpreters or assessed bilingual providers and 

bilingual workers/employees during critical times in a patient’s 

health care experience. 

Language 

services 

NQF #1821—L2: 

Patients receiving 

language services 

supported 

by qualified 

language 

services providers 

(measure 

steward: George 

Washington 

University 

Department of 

Health Policy) 

Applicable to all 

settings 

NQF, 2012b 

NQF, 2012f 

Screening 

for preferred 

spoken 

language for 

health care 

This measure is used to assess the percentage of patient 

visits and admissions where preferred spoken language for 

health care is screened and recorded. This measure provides 

information on the extent to which patients are asked about 

the language they prefer to receive care in and the extent to 

which this information is recorded. 

Language 

screening 

NQF #1824— 

L1A: Screening 

for preferred 

spoken language 

for health 

care (measure 

steward: George 

Washington 

University 

Department of 

Health Policy) 

Applicable to 

ambulatory 

care, hospital, 

and behavioral 

health settings 

NQF, 2012a 

NQF, 2012f 

164 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURE(S) DESCRIPTION 

AREA OF 

FOCUS SOURCE ID NOTES REFERENCE 

Cultural 

Competency 

Implementation Measure 

The Cultural Competency Implementation Measure is an organizational survey designed to assist HCOs in identifying the 

degree to which they are providing culturally competent care 

and addressing the needs of diverse populations, as well as their 

adherence to 12 of the 45 NQF-endorsed cultural competency 

practices prioritized for the survey. Domains include leadership, integration into the management system and operations, 

patient-provider communication, care delivery and supporting mechanisms, workforce diversity and training, community 

engagement, data collection, public accountability, and quality 

improvement. 

Cultural 

competency 

implementation 

NQF #1919— 

Cultural 

Competency 

Implementation 

Measure (measure 

steward: RAND 

Corporation) 

Applicable to 

ambulatory 

care, hospital, 

and behavioral 

health settings 

These measures 

have yet to be 

tested/validated. 

NQF, 2012e 

NQF, 2012f 

C-CAT C-CAT, which has been extensively validated in diverse HCOs nationally, provides a 360-degree organizational assessment using 

coordinated patient, staff, and leadership surveys, as well as an 

organizational workbook that collects important information on 

the organization’s policies and practices. 

When analyzed together, C-CAT’s tools provide tangible, reliable 

metrics that demonstrate whether an organization’s policies, 

practices, and culture promote effective, patient-centered communication. Trained consultants provide guidance and assistance 

throughout the assessment, conduct statistical analysis of data 

(including comparisons against a national benchmarking database) and create a feedback report featuring personalized, 

site-specific recommendations. 

In addition to helping maximize the impact of performance improvement efforts, the use of C-CAT provides valuable information regarding needs assessments and meeting local and national standards. Organizations using C-CAT find that it compliments 

CAHPS assessments, documents compliance with Title VI (CLAS) 

standards, and is invaluable in meeting The Joint Commission’s 

patient-centered communication standards. 

Communication 

climate 

C-CAT survey 

(measure steward: 

University of 

Colorado Center 

for Bioethics and 

Humanities) 

Applicable to all 

settings 

Center for 

Bioethics 

and 

Humanities, 

undated 

NQF, 2012f 

165 
APPENDIX E: CROSS-CUTTING MEASURES
 

TABLE E.2. CROSS-CUTTING MEASURES: ADDITIONAL DETAILS
 

MEASURES ITEMS
 

Clinician/group’s 

cultural competence 

based on the CAHPS 

Cultural Competence 

Item Set 

These measures are based on the CAHPS Cultural Competence Item Set, a set of supplemental items for the CG-CAHPS that 

includes the following domains: patient-provider communication; complementary and alternative medicine; experiences of 

discrimination because of race/ethnicity, insurance, or language; experiences leading to trust or distrust, including level of 

trust, caring, and confidence in the truthfulness of their provider; and linguistic competency (access to language services). 

Samples for the survey are drawn from adults who have had at least one provider visit within the past year. Measures can 

be calculated at the individual clinician level or at the group (e.g., practice, clinic) level. 

Patient-provider 

communication 

(Note: CU3, CU5, 

and CU8 form 

a composite 

measure: Providers 

are polite and 

considerate) 

CU1: In the last 12 months, how often were the explanations this provider gave you hard to understand because of an
 

accent or the way the provider spoke English?
 

CU2: In the last 12 months, how often did this provider use medical words you did not understand?
 

CU3: In the last 12 months, how often did this provider talk too fast when talking with you?
 

CU4: In the last 12 months, how often did this provider ignore what you told him or her?
 

CU5: In the last 12 months, how often did this provider interrupt you when you were talking?
 

CU6: In the last 12 months, how often did this provider show interest in your questions and concerns?
 

CU7: In the last 12 months, how often did this provider answer all of your questions to your satisfaction?
 

CU8: In the last 12 months, how often did this provider use a condescending, sarcastic, or rude tone or manner with you?
 

Complementary 

and alternative 

medicine 

CU9: People sometimes see someone else besides their providers or specialists to help with an illness or to stay healthy. In 

the last 12 months, have you ever used an acupuncturist? 

CU10: In the last 12 months, have you ever used an herbalist? 

CU11: In the last 12 months, has this provider ever asked you if you have used an acupuncturist or an herbalist to help with 

an illness or to stay healthy? 

CU12: Some people use natural herbs for health reasons or to stay healthy. Natural herbs include such things as ginseng, 

green tea, and other herbs. People can take them as a pill, a tea, an oil, or a powder. In the last 12 months, have you ever 

used natural herbs for your own health? 

CU13: In the last 12 months, has this provider ever asked you if you used natural herbs? 

166 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS 

Experiences of 

discrimination 

because of 

race/ethnicity, 

insurance, or 

language 

CU14: In the last 12 months, how often have you been treated unfairly at this provider's office because of your race or 

ethnicity? 

CU15: In the last 12 months, how often have you been treated unfairly at this provider’s office because of the type of 

health insurance you have or because you do not have health insurance? 

Experiences 

leading to trust or 

distrust, including 

level of trust, 

caring, and truthtelling 

(Note: CU16–CU20 

form a composite 

measure: Providers 

are caring and 

inspire trust.) 

CU16: In the last 12 months, did you feel you could tell this provider anything, even things that you might not tell anyone 

else? 

CU17: In the last 12 months, did you feel you could trust this provider with your medical care? 

CU18: In the last 12 months, did you feel that this provider always told you the truth about your health, even if there was 

bad news? 

CU19: In the last 12 months, did you feel this provider cared as much as you do about your health? 

CU20: In the last 12 months, did you feel this provider really cared about you as a person? 

CU21: Using any number from 0 to 10, where 0 means that you do not trust this provider at all and 10 means that you trust 

this provider completely, what number would you use to rate how much you trust this provider? 

167 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS 

Linguistic 

competency (access 

to language 

services) 

CU22: What is your preferred language? 

CU23: How well do you speak English? 

CU24: In the last 12 months, how often were you treated unfairly at this provider’s office because you did not speak English 

very well? 

CU25: An interpreter is someone who helps you talk with others who do not speak your language. Interpreters can include 

staff from the provider’s office or telephone interpreters. In the last 12 months, was there any time when you needed an 

interpreter at this provider’s office? 

CU26: In the last 12 months, did anyone in this provider’s office let you know that an interpreter was available free of 

charge? 

CU27: In the last 12 months, how often did you use an interpreter provided by this office to help you talk with this 

provider? 

CU28: In the last 12 months, when you used an interpreter provided by this office, who was the interpreter you used most 

often? 

CU29: In the last 12 months, how often did this interpreter treat you with courtesy and respect? 

CU30: Using any number from 0 to 10, where 0 is the worst interpreter possible and 10 is the best interpreter possible, what 

number would you use to rate this interpreter? 

CU31: In the last 12 months, did any of your appointments with this provider start late? 

CU32: Did any of your appointments start late because you had to wait for an interpreter? 

CU33: In the last 12 months, how often did you use a friend or family member as an interpreter when you talked with this 

provider? 

CU34: In the last 12 months, did you use friends or family members as interpreters because that was what you preferred? 

Clinician/groups’ 

health literacy 

practices based on 

the CAHPS Item 

Set for Addressing 

Health Literacy 

These measures are based on the CAHPS Item Set for Addressing Health Literacy, a set of supplemental items for the CGCAHPS. The item set includes the following domains: communication with provider (doctor), disease self-management, 

communication about medicines, communication about test results, and communication about forms. Samples for the 

survey are drawn from adults who have had at least one provider visit within the past year. Measures can be calculated at 

the individual clinician level or at the group (e.g., practice, clinic) level. 

168 
 

APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS 

Communication 

with provider 

HL1: In the last 12 months, how often were the explanations this provider gave you hard to understand because of an 

accent or the way the provider spoke English? 

HL2: In the last 12 months, how often did this provider use medical words you did not understand? 

HL3: In the last 12 months, how often did this provider talk too fast when talking with you? 

HL4: In the last 12 months, how often did this provider use pictures, drawings, models, or videos to explain things to you? 

HL5: In the last 12 months, how often did this provider ignore what you told him or her? 

HL6: In the last 12 months, how often did this provider interrupt you when you were talking? 

HL7: In the last 12 months, how often did this provider show interest in your questions and concerns? 

HL8: In the last 12 months, how often did this provider answer all of your questions to your satisfaction? 

HL9: In the last 12 months, how often did this provider give you all the information you wanted about your health? 

HL10: In the last 12 months, how often did this provider encourage you to talk about all your health questions or concerns? 

HL17: In the last 12 months, how often did this provider use a condescending, sarcastic, or rude tone or manner with you? 

Disease selfmanagement HL11: In the last 12 months, did you see this provider for a specific illness or for any health condition? 

HL12: In the last 12 months, did this provider give you instructions about what to do to take care of this illness or health 

condition? 

HL13: In the last 12 months, how often were these instructions easy to understand? 

HL14: In the last 12 months, how often did this provider ask you to describe how you were going to follow these 

instructions? 

HL15: Sometimes providers give instructions that are hard to follow. In the last 12 months, how often did this provider ask 

you whether you would have any problems doing what you needed to do to take care of this illness or health condition? 

HL16: In the last 12 months, how often did this provider explain what to do if this illness or health condition got worse or 

came back? 

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APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS 

Communication 

about medicines 

(Note: HL20, HL22, 

HL24, and HL26 

form a composite 

measure: Providers 

communicate 

about medicines.) 

HL19: In the last 12 months, did this provider prescribe any new medicines or change how much medicine you should take? 

HL20: In the last 12 months, did this provider give instructions about how to take your medicines? 

HL21: In the last 12 months, how often were these instructions about how to take you medicines easy to understand? 

HL22: In the last 12 months, did this provider explain the possible side effects of your medicines? 

HL23: In the last 12 months, how often were these explanations easy to understand? 

HL24: In the last 12 months, other than a prescription, did this provider give you written information or write down 

information about how to take your medicines? 

HL25: In the last 12 months, how often was the written information you were given easy to understand? 

HL26: In the last 12 months, how often did this provider suggest ways to help you remember to take your medicines? 

Communication 

about test results 

Core 21: In the last 12 months, did this provider order a blood test, X-ray, or other test for you? 

Core 22: In the last 12 months, when this provider ordered a blood test, X-ray, or other test for you, how often did someone 

from this provider’s office follow up to give you those results? 

HL26: In the last 12 months, how often were the results of your blood test, X-ray, or other test easy to understand? 

Communication 

about forms 

HL27: In the last 12 months, did you sign any forms at this provider’s office? 

HL28: In the last 12 months, how often did someone explain the purpose of a form before you signed it? 

HL29: In the last 12 months, did you fill out any forms at this provider’s office? 

HL30: In the last 12 months, how often were you offered help to fill out a form at this provider’s office? 

HL31: In the last 12 months, how often were the forms from this provider’s office easy to fill out? 

Cultural Competency 

Implementation 

Measure 

The Cultural Competency Implementation Measure is an organizational survey designed to assist HCOs in identifying the 

degree to which they are providing culturally competent care and addressing the needs of diverse populations, as well as 

their adherence to 12 of the 45 NQF-endorsed cultural competency practices prioritized for the survey. The target audience 

for this survey includes HCOs across a range of health care settings, including hospitals, health plans, community clinics, and 

dialysis organizations. Information from the survey can be used for QI, provide information that can help HCOs establish 

benchmarks and assess how they compare in relation to peer organizations, and for public reporting. 

Domains include leadership, integration into the management system and operations, patient-provider communication, 

care delivery and supporting mechanisms, workforce diversity and training, community engagement, data collection, public 

accountability, and quality improvement. 

170 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS 

Subdomain: 

commitment to 

serving a diverse 

population 

Has your organization: 

1. reviewed its vision statement, goals, and mission to ensure that they reflect a commitment to culturally competent care? 

2. provided staff members with the opportunity to provide input and comment on the action plan for providing culturally 

competent care? 

3. made the vision statement, goals, mission, and the action plan for providing culturally competent care publicly available 

throughout the organization and the community? 

4. developed and/or revised the organization’s vision statement, goals, and mission to ensure that it reflects a commitment 

to providing high-quality, culturally competent care for diverse populations? 

5. developed an action plan that includes explicit expectations and measureable objectives relating to culturally competent 

care? 

6. implemented or updated the action plan for providing high-quality, culturally competent care to the diverse populations 

your organization serves? 

Subdomain: 

leadership diversity 

Has your organization: 

1. reviewed the strategies for staff recruitment and the selection processes to assess whether staff at all levels of the 

organization reflect the demographic characteristics of the service area? 

2. ensured that staff recruitment and selection processes focus on meeting the needs of the organization’s goals for 

culturally competent care? 

3. sought input from community leaders on strategies to recruit, retain, and promote staff at all levels of the organization 

(including upper management)? 

4. used a committee of current diverse staff to develop strategies for recruitment, retention, and promotion of staff that 

reflect the community at all levels of the organization (including upper management)? 

5. conducted an internal assessment on how to address the need for staff diversity at all levels of the organization, 

including upper management? 

6. conducted an external assessment on how to address the need for staff diversity at all levels of the organization, 

including upper management? (This can include obtaining data on the demographic characteristics of the service area and 

comparing it to the diversity of staff.) 

7. developed or implemented strategies for recruiting, retaining, and promoting a diverse staff at all levels of the 

organization, including upper management? 

8. advertised and recruited from the community served? 

171 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS 

Subdomain: 

dedicated staff 

and resources 

Have your organization’s leaders: 

1. consulted with the care setting managers, clinical leaders, language service providers, and others to identify needed fiscal 

resources to appropriately meet the cultural needs of patients? 

2. consulted with the care setting managers, clinical leaders, language service providers, and others to identify needed 

human resources to appropriately meet the cultural needs of patients? 

3. documented where the fiscal support for culturally competent policies and practices is within the organization? 

4. established and enforced organizational policies that support the allocation of fiscal resources for cultural competency? 

5. ensured that there are budget line items and specific allocations for cultural competency activities and programs that 

reflect the organization’s goals for providing culturally competent care? 

6. provided staff with time and resources for training programs and practices that promote culturally competent care? 

7. provided training and coaching on culturally competent care to new staff? 

8. provided continued training and coaching on culturally competent care to current staff? 

Subdomain: 

strategic planning 

Has your organization: 

1. reviewed the organizational strategic plan to ensure that it has clear goals that include providing culturally competent 

services? 

2. involved consumers and the community served in the development of a strategic plan that has clear goals that include 

providing culturally competent services? 

3. involved staff in the development of a strategic plan that has clear goals that include providing culturally competent 

services? 

4. gathered data on community needs to inform the development and refinement of goals, plans, and policies for 

providing culturally competent care as part of the organizational strategic plan? 

5. conducted an organizational self-assessment to inform the development and refinement of goals, plans, and policies for 

providing culturally competent care as part of the organizational strategic plan? 

6. used results from the community needs assessment and self-assessment processes to inform the development and 

refinement of goals, plans, and policies for providing culturally competent care as part of the organizational strategic plan? 

172 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS 

Subdomain: 

reward systems 

Has your organization: 

1. reviewed job performance evaluation criteria to assess staff to ensure that they include specific improvement goals 

related to cultural competence? 

2. reviewed evaluation criteria used to assess initiatives and programs within the organization that promote cultural 

competence? 

3. compared job performance evaluation criteria that include aspects of cultural competence with other recognition 

activities and awards to make sure they are on equal par? 

4. compared evaluation criteria to assess initiatives and programs that promote cultural competence with other recognition 

activities and awards to make sure they are on equal par? 

5. established standardized evaluation criteria that include aspects of cultural competence to assess individuals within the 

organization who promote cultural competency? 

6. established standardized evaluation criteria that include aspects of cultural competence to assess initiatives and programs 

within the organization that promote cultural competency? 

7. rewarded or recognized individuals within the organization who improve cultural competency and reduce health care 

disparities or who go beyond the preferred practices included in the Framework and Preferred Practices for Measuring and 

Reporting on Cultural Competency? 

8. rewarded or recognized initiatives or programs within the organization that improve cultural competency and reduce 

health care disparities or that go beyond the preferred practices included in the Framework and Preferred Practices for 

Measuring and Reporting on Cultural Competency? 

173 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES	 ITEMS
 

Subdomain:	 

language access	 

Has your organization: 

1. reviewed its language assistance resource policies to ensure that it is providing language assistance to persons with LEP 

at no cost to them? 

2. reviewed language assistance services available in different areas of the organization? 

3. reviewed wait times for language assistance services available in different areas of the organization? 

4. evaluated the qualifications of all staff providing interpreting services or care directly provided in another language to 

patients? 

5. assessed the competency of all staff providing interpreting services or care directly provided in another language to 

patients? 

6. monitored all staff providing interpreting services or care directly provided in another language to patients to determine 

competency to provide services in health care settings? 

7. created uniform procedures for timely and effective telephone communication between staff and LEP patients? 

8. informed individuals with LEP—in their primary language—that they have the right to free language assistance services 

and that such services are readily available? 

9. distributed, at points of contact, written notices with information informing patients that they have the right to free 

language assistance services and that such services are readily available? 

10. used language identification or “I speak. . . ” cards to inform patients that they have the right to free language 

assistance services and that such services are readily available? 

11. posted translated signage at points of entry in regularly encountered languages that language assistance services are 

available free of charge? 

12. distributed to the public brochures, booklets, outreach materials, and other materials in regularly encountered nonEnglish languages that include statements about the language assistance services available and the right to free language 

assistance services? 

13. provided qualified language resources, including competent interpreters (staff, contractors from outside agencies, 

remote telephonic or video interpreting services, or credentialed volunteers) and/or bilingual/multilingual clinical staff for 

clinical encounters? 

14. provided bilingual/multilingual general staff as navigators for other encounters (e.g., to assist in making appointments, 

assist with transfers within a facility)? 

174 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS


Subdomain: clinical 

encounter 

Within the past 12 months, how often has your organization: 

1. reviewed patient care plans provided to patients to ensure that they address the physical, cultural, and social needs of
 

the patient, including cultural background, religion, and spiritual belief system?
 

Within the past 12 months, has your organization:
 

2. developed a comprehensive care plan with patients and their caregivers to ensure that the plan addresses the physical,
 

cultural, and social needs of the patient, including cultural background, religion, and spiritual belief system?
 

Within the past 12 months, how often has your organization:
 

3. collected information on patients’ and families’ primary written and spoken languages and any cultural beliefs that
 

might affect the care plan, including but not limited to those involving spirituality/religion, nation of origin, and ethnicity?
 

Within the past 12 months, has your organization:
 

4. implemented comprehensive care plans that address the physical, cultural, and social needs of the patient, including
 

cultural background, religion, and spiritual belief system?
 

Subdomain: 

training 

commitment and 

content 

Has your organization: 

1. reviewed training materials and programs used to provide cultural competence training? 

2. assessed its progress in recruiting, hiring, and retaining qualified, diverse staff at all levels of the organization? 

3. evaluated cultural competence training programs to ensure that managers and staff at all levels receive training that is 

effective, relevant, and up to date? 

4. had human resource managers assess the qualifications of staff responsible for cultural competency training? 

5. had human resource managers assess and report on employee promotions, terminations, and resignations to evaluate 

how well the organization is doing in the promotion and retention of a diverse workforce? 

6. developed or updated training materials or programs to increase staff awareness of the cultural needs, beliefs, and 

attitudes of the predominant populations served by the organization? 

7. included or updated training materials or programs to provide staff with in-depth information about the causes of and 

research on cultural competency, inequities, and health care disparities? 

8. provided staff with time and resources for training programs and practices that promote culturally competent care? 

9. provided training and coaching to new staff to increase cultural competency awareness, knowledge, and skills? 

10. provided training and coaching to current staff to increase cultural competency awareness, knowledge, and skills? 

175 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS 

Subdomain: 

community 

outreach 

Has your organization: 

1. identified resources in the community to develop training programs, research projects, and outreach activities to help 

understand and address the cultural needs of the communities served? 

2. created a community advisory board that is representative of the diverse community served by the organization? 

3. established or maintained collaborative relationships with community organizations to help understand and address the 

cultural needs of the communities served? 

4. worked with community organizations on specific health education programs to raise awareness about local health care 

services? 

5. utilized community experience and resources to develop training programs, research projects, or outreach activities to 

address the needs of culturally diverse populations, or to address health care disparities and equity in the community? 

Subdomain: 

collection of 

patient cultural 

competencyrelated 

information 

Has your organization: 

1. reviewed patient data on race/ethnicity to ensure that you are collecting this information using Office of Management 

and Budget (OMB) categories as modified by HRET231? 

2. reviewed data from health records to ensure that data on an individual patient’s race/ethnicity and primary written and 

spoken language are collected? 

3. reviewed data from your organization’s management information system to ensure data from patients’ health records on 

an individual patient’s race and ethnicity and primary written and spoken language are integrated into the management 

information systems? 

4. reviewed policies and procedures to ensure that patients’ race/ethnicity data is not used for discriminatory purposes? 

5. developed, maintained, or improved the process for collecting data on an individual patient’s race and ethnicity and 

primary written and spoken language in the patient’s health record? 

6. developed, maintained, or improved the process for integrating data on an individual patient’s race/ethnicity and 

primary written and spoken language into management information systems? 

176 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS
 

Subdomain: quality 

improvement 

Has your organization: 

1. identified NQF-endorsed performance measures to collect and use for QI activities focused on providing more culturally 

competent care and discovering and eliminating health care disparities in access, outcomes, or patient experiences with 

care? 

2. based on national benchmarks, set organizational targets and benchmarks for performance measures? 

3. utilized performance improvement methodology and science, such as rapid-cycle change and Plan-Do-Study-Act cycles 

to implement QI activities focused on providing more culturally competent care and eliminating health care disparities in 

access, outcomes, or patient experiences with care? 

4. used information on patients’ race, ethnicity, and primary written and spoken language to design and/or inform QI 

strategies and projects focused on providing more culturally competent care and eliminating health care disparities in 

access, outcomes, or patient experiences with care? 

5. implemented QI strategies or projects focused on providing more culturally competent care and eliminating health care 

disparities in access, outcomes, or patient experiences with care? 

Subdomain: 

assessment 

of patient 

experiences with 

care 

Within the past 12 months, has your organization: 

1. collected information on model health care programs that use patient- and family-centered communication? 

2. conducted site visits to successful health care programs that use patient- and family-centered communication? 

3. consulted published guides on improving patient-provider communication? 

4. utilized focus groups or patient surveys in the patient’s preferred language, to collect data on patient experience of care 

as it relates to patient-provider communication? 

5. collected data or sought input from staff on patient and family communication needs and performance? 

6. utilized a patient survey to collect patient experience of care data that is being publicly reported either by your 

organization or by another organization? 

7. designed communication initiatives based on the needs of patients, families, and staff? 

8. used champions to build support for new communication initiatives by presenting qualitative and quantitative data on 

patient and family communication needs and staff performance? 

9. implemented communication initiatives designed to improve patient and family-centered communication? 

10. utilized findings from patient focus groups or patient surveys to assess whether patients and their families find that 

patient-provider communication is effective? 

177 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS 

C-CAT C-CAT, which has been extensively validated in diverse HCOs nationally, provides a 360-degree organizational assessment 

using coordinated patient, staff, and leadership surveys, as well as an organizational workbook that collects important 

information on the organization’s policies and practices. 

When analyzed together, C-CAT’s tools provide tangible, reliable metrics that demonstrate whether an organization’s 

policies, practices, and culture promote effective, patient-centered communication. Trained consultants provide guidance 

and assistance throughout the assessment, conduct statistical analysis of data (including comparisons against a national 

benchmarking database) and create a feedback report featuring personalized, site-specific recommendations. 

In addition to helping maximize the impact of performance improvement efforts, the use of C-CAT provides valuable 

information regarding needs assessments and meeting local and national standards. Organizations using C-CAT find that 

it compliments CAHPS assessments, documents compliance with Title VI (CLAS) Standards and is invaluable in meeting The 

Joint Commission’s patient-centered communication standards. 

Workforce 

development 

measure 

derived from 

the workforce 

development 

domain of the 

C-CAT 

Site score on the measure domain of “workforce development” of the C-CAT, 0–100 

Leadership 

commitment 

measure 

derived from 

the leadership 

commitment 

domain of the 

178 

C-CAT 

Site score on the measure derived from the domain of “leadership commitment” of the C-CAT, 0–100 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS 

Cross-cultural 

communication 

measure derived 

from the 

cross-cultural 

communication 

domain of the 

C-CAT 

Site score for “cross-cultural communication” domain of the C-CAT, 0–100 

Health literacy 

measure derived 

from the health 

literacy domain of 

the C-CAT 

Site score on the domain of “health literacy” of the C-CAT, 0–100 

Performance 

evaluation 

measure derived 

from the 

performance 

evaluation domain 

of the C-CAT 

Site score on domain of “performance evaluation” of the C-CAT, 0–100 

Individual 

engagement 

measure derived 

from the individual 

engagement 

domain of the 

C-CAT 

Site score on “individuals’ engagement” domain of patient-centered communication, per the C-CAT, 0–100 

179 
APPENDIX E: CROSS-CUTTING MEASURES
 

MEASURES ITEMS 

Language services 

measure derived 

from the language 

services domain of 

the C-CAT 

Site score on the domain of “language services” of the C-CAT, 0–100 

180 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

References
 

Acosta, Joie D., Anita Chandra, Malcolm Williams, and Lois M. Davis, Source Materials for the Healthy 

Communities Toolkit: A Resource Guide for Community and Faith-Based Organizations, Santa 

Monica, Calif.: RAND Corporation, TR-951-DHHS, 2011. As of August 18, 2016: 

http://www.rand.org/pubs/technical_reports/TR951.html 

Adepoju, Omolola E., Michael A. Preston, and Gilbert Gonzales, “Health Care Disparities in the Post– 

Affordable Care Act Era,” American Journal of Public Health, Vol. 105, No. 5, November 2015, 

pp. S665–S667. 

Agency for Healthcare Research and Quality, “CAHPS Surveys and Tools to Advance Patient-Centered 

Care,” undated. As of August 22, 2016: 

http://www.ahrq.gov/cahps/index.html 

———, About the CAHPS Cultural Competency Set, Rockville, Md., No. 2312, May 1, 2012. As of 

November 10, 2017: 

https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/survey4.0-docs/ 

2312_about_cultural_comp.pdf 

———, “2012 National Healthcare Disparities Report,” Rockville, Md., June 2013a. As of August 18, 2016: 

https://archive.ahrq.gov/research/findings/nhqrdr/nhdr12/2012nhdr.pdf 

———, “CAHPS Clinician & Group Survey,” webpage, June 2013b. As of November 10, 2017: 

https://www.ahrq.gov/cahps/surveys-guidance/cg/index.html 

———, “CAHPs Hospital Survey,” webpage, October 2014. As of November 10, 2017: 

https://www.ahrq.gov/cahps/surveys-guidance/hospital/index.html 

———, “Experience of Care & Health Outcomes (ECHO),” Rockville, Md., May 2016. As of November 10, 

2017: 

http://www.ahrq.gov/cahps/surveys-guidance/echo/index.html 

AHA—See American Hospital Association. 

181 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

AHRQ—See Agency for Healthcare Research and Quality. 

Alegria, Margarita, Pinka Chatterji, Kenneth Wells, Zuhn Cao, Chih-nan Chen, David Takeuchi, James 

Jackson, and Xiao-Li Meng, “Disparity in Depression Treatment Among Racial and Ethnic Minority 

Populations in the United States,” Psychiatric Services, Vol. 59, No. 11, November 2008, pp. 1264– 

1272. 

Alley, Dawn E., Chisara N. Asomugha, Patrick H. Conway, and Darshak M. Sanghavi, “Accountable Health 

Communities—Addressing Social Needs Through Medicare and Medicaid,” New England Journal of 

Medicine, Vol. 374, No. 1, 2016, pp. 8–11. 

American Hospital Association, “Fast Facts on U.S. Hospitals,” January 2016. As of November 10, 2017: 

http://www.aha.org/research/rc/stat-studies/fast-facts.shtml 

American Hospital Association and the Institute for Diversity in Health Management, Diversity and 

Disparities: A Benchmark Study of U.S. Hospitals, Chicago, Ill.: The Health Research and Educational 

Trust, 2012. 

American Psychological Association, Guidelines on Multicultural Education, Training, Research, Practice, 

and Organizational Change for Psychologists, 2002. As of November 10, 2017: 

http://www.apa.org/pi/oema/resources/policy/multicultural-guidelines.aspx 

Anderson, Laurie M., Susan C. Scrimshaw, Mindy T. Fullilove, Jonathan E. Fielding, and Jacques Normand, 

“Culturally Competent Healthcare Systems: A Systematic Review,” American Journal of Preventive 

Medicine, Vol. 24, No. 3, April 2003, pp. 68–79. 

Barksdale, Crystal L., Phyllis Gyamfi Ottley, Robert Stephens, Tesfayi Gebreselassie, Imogen Fua, Melissa 

Azur, and Christine Walrath-Greene, “System-Level Change in Cultural and Linguistic Competence 

(CLC): How Changes in CLC are Related to Service Experience Outcomes in Systems of Care,” 

American Journal of Community Psychology, Vol. 49, No. 3–4, 2012, pp. 483–493. 

182 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Berkman, Nancy D., Stacey L. Sheridan, Katrina E. Donahue, David J. Halpern, and Karen Crotty, “Low Health 

Literacy and Health Outcomes: An Updated Systematic Review,” Annals of Internal Medicine, Vol. 155, 

No. 2, 2011, pp. 97–107. As of November 10, 2017: 

http://annals.org/aim/article-abstract/747040/low-health-literacy-health-outcomes-updated-systematicreview?doi=10.7326%2f0003-4819-155-2-201107190-00005 

Beronio, Kirsten, Rosa Po, Laura Skopec, and Sherry Glied, Affordable Care Act Expands Mental Health and 

Substance Use Disorder Benefits and Federal Parity Protections for 62 Million Americans, Washington, 

D.C.: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and 

Evaluation, February 20, 2013. As of August 18, 2016: 

https://aspe.hhs.gov/report/affordable-care-act-expands-mental-health-and-substance-use-disorderbenefits-and-federal-parity-protections-62-million-americans 

Betancourt, Joseph R., Alexander R. Green, and J. Emilio Carrillo, Cultural Competence in Health Care: 

Emerging Frameworks and Practical Approaches, New York: The Commonwealth Fund, 2002. 

Betancourt, Joseph R., Alexander R. Green, J. Emilio Carrillo, and Owusu Ananeh-Firempong, II, “Defining 

Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and 

Health Care,” Public Health Reports, Vol. 118, No. 4, July–August 2003, pp. 293–302. As of November 9, 

2017: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497553/pdf/12815076.pdf 

Betancourt, Joseph R., Aswita Tan-McGrory, and Karey S. Kenst, Guide to Preventing Readmissions Among 

Racially and Ethnically Diverse Medicare Beneficiaries, Baltimore, Md.: Centers for Medicare & Medicaid 

Services Office of Minority Health, September 2015. As of November 10, 2017: 

https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/OMH_Readmissions_Guide.pdf 

“Be There San Diego,” homepage, undated. As of August 22, 2016: 

http://betheresandiego.org/ 

Brach, Cindy, and Irene Fraser, “Can Cultural Competency Reduce Racial and Ethnic Health Disparities? A 

Review and Conceptual Model,” Medical Care Research Review, Vol. 57, No. 1, 2000, pp. 181–217. As of 

November 10, 2017: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5091811/pdf/nihms825245.pdf 

183 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

———, “Reducing Disparities Through Culturally Competent Health Care: An Analysis of the Business Case,” 

Quality Management in Health Care, Vol. 10, No. 4, Summer 2002, pp. 15–28. 

Brach, Cindy, Kathryn Paez, and Irene Fraser, Cultural Competence California Style, Rockville, Md.: Agency for 

Healthcare Research and Quality, February 2006. 

Briefer French, Jessica, Diane Schiff, Esther Han, and Robin Weinick, Multicultural Health Care: A Quality 

Improvement Guide, Washington, D.C.: The National Committee for Quality Assurance, 2008. As of 

November 10, 2017: 

https://innovations.ahrq.gov/qualitytools/multicultural-health-care-quality-improvement-guide 

Brownson, Ross C., Peg Allen, Kathleen Duggan, Katherine A. Stamatakis, and Paul C. Erwin, “Fostering 

More-Effective Public Health by Identifying Administrative Evidence-Based Practices: A Review of the 

Literature,” American Journal of Preventive Medicine, Vol. 43, No. 3, 2012, pp. 309–319. 

Bureau of Primary Health Care, Uniform Data System: Reporting Instructions for Health Centers, Rockville, 

Md.: Health Resources and Services Administration, September 3, 2015. As of August 22, 2016: 

https://bphc.hrsa.gov/datareporting/reporting/2015udsmanual.pdf 

Campinha-Bacote, Josepha, “The Process of Cultural Competence in the Delivery of Healthcare Services: A 

Model of Care,” Journal of Transcultural Nursing, Vol. 13, No. 3, July 2002, pp. 181–184. 

CDC—See Centers for Disease Control and Prevention. 

CDC NCHS—See Centers for Disease Control and Prevention, National Center for Health Statistics. 

California Department of Public Health, Title 17, California Code of Regulations §2500, §2593, §2641.5– 

2643.20, and §2800–2812, Reportable Diseases and Conditions, July 2016. 

Center for Bioethics and Humanities, “C-CAT Surveys,” webpage, University of Colorado Anschutz Medical 

Campus, undated. As of November 10, 2017: 

http://www.ucdenver.edu/academics/colleges/medicalschool/centers/BioethicsHumanities/C-CAT/Pages/ 

C-CAT-Surveys.aspx 

184 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Centers for Disease Control and Prevention, “Introduction to Program Evaluation for Public Health Programs: 

A Self-Study Guide,” webpage, May 11, 2012. As of November 6, 2017: 

https://www.cdc.gov/eval/guide/introduction/ 

———, Community Needs Assessment: Participant Workbook, Atlanta, Ga., 2013. As of November 6, 2017: 

https://www.cdc.gov/globalhealth/healthprotection/fetp/training_modules/15/community-needs_pw_ 

final_9252013.pdf 

———, “Core Functions of Public Health and How They Relate to the 10 Essential Services,” webpage, 

June 10, 2016a. As of August 19, 2016: 

http://www.cdc.gov/nceh/ehs/ephli/core_ess.htm 

———, “Ambulatory Care Use and Physician Office Visits,” data set, June 13, 2016b. As of August 22, 2016: 

http://www.cdc.gov/nchs/fastats/physician-visits.htm 

———, “Developing and Using a Logic Model,” Atlanta, Ga., January 19, 2017a. As of November 6, 2017: 

https://www.cdc.gov/dhdsp/programs/spha/evaluation_guides/logic_model.htm 

———, “State, Tribal, Local & Territorial Public Health Professionals Gateway: The Public Health System and 

the 10 Essential Public Health Services,” webpage, September 20, 2017b. As of November 10, 2017: 

https://www.cdc.gov/stltpublichealth/publichealthservices/essentialhealthservices.html 

Centers for Disease Control and Prevention, National Center for Health Statistics, “National Hospital 

Ambulatory Medical Care Survey: 2011 Outpatient Department Summary Tables,” undated. As of 

November 10, 2017: 

https://www.cdc.gov/nchs/data/ahcd/nhamcs_outpatient/2011_opd_web_tables.pdf 

———, Association of State and Territorial Health Officials, Policies for Eliminating Healthcare-Associated 

Infections: Lessons from State Stakeholder Engagement, 1987. 

———, “Hospital Utilization (in Non-Federal Short-Stay Hospitals),” April 2016. As of November 10, 2017: 

http://www.cdc.gov/nchs/fastats/hospital.htm 

185 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Centers for Medicare & Medicaid Services, “Accountable Health Communities (AHC) Model Fact Sheet,” 

January 5, 2016a. As of August 22, 2016: 

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/ 

2016-01-05.html 

———, “CMS Releases Interactive Mapping Medicare Disparities Tool,” press release, March 17, 2016b. As of 

August 22, 2016: 

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releasesitems/2016-03-17.html 

Chen, Alice H., Mara K. Youdelman, and Jamie Brooks, “The Legal Framework for Language Access in 

Healthcare Settings: Title VI and Beyond,” Journal of General Internal Medicine, Vol. 22, No. 2, November 

2007, pp. 362–367. As of August 22, 2016: 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2150609/ 

Chinman, Matthew, Pamela Imm, and Abraham Wandersman, Getting to Outcomes 2004: Promoting 

Accountability Through Methods and Tools for Planning, Implementation, and Evaluation, Santa Monica, 

Calif.: RAND Corporation, TR-101-CDC, January 2004. As of October 31, 2017: 

https://www.rand.org/pubs/technical_reports/TR101.html 

CMS—See Centers for Medicare & Medicaid Services. 

Community Tool Box, “2. Assessing Community Needs and Resources,” undated(a). As of November 6, 2017: 

http://ctb.ku.edu/en/assessing-community-needs-and-resources 

———, “Chapter 3: Section 1. Developing a Plan for Accessing Local Needs and Resources,” undated(b). As of 

November 6, 2017: 

http://ctb.ku.edu/en/table-of-contents/assessment/assessing-community-needs-and-resources/ 

develop-a-plan/main 

Consumer Partnership for eHealth, Leveraging Meaningful Use to Reduce Health Disparities: An Action Plan, 

Washington, D.C.: National Partnership for Women and Families, August 2013. As of November 10, 2017: 

http://www.nationalpartnership.org/research-library/health-care/HIT/leveraging-meaningful-use-to.pdf 

186 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

COSMOS Corporation, Developing a Self-Assessment Tool for Culturally and Linguistically Appropriate Services 

in Local Public Health Agencies: Final Report, Bethesda, Md., December 2003. As of November 10, 2017: 

http://minorityhealth.hhs.gov/assets/pdf/checked/lphas_finalreport.pdf 

CyraCom, LLC, How Language Services are Provided in Hospitals Across the U.S.: Survey Results, 2010. As of 

November 10, 2017: 

http://img.en25.com/Web/CyraComInternationalInc/%7B6f50fa62-512c-4ffd-9f6d-f2d0a626be26%7D_ 

Whitepaper_-_How_Language_Services_are_Provided_in_Hospitals_Across_the_US.pdf 

Dansky, Kathryn H., Robert Weech-Maldonado, Gita De Souza, and Janice L. Dreachslin, “Organizational 

Strategy and Diversity Management: Diversity-Sensitive Orientation as a Moderating Influence,” Health 

Care Management Review, Vol. 28, No. 3, July–September 2003, pp. 243–253. As of November 10, 2017: 

https://insights.ovid.com/pubmed?pmid=12940346 

Davidson, Patricia M., Peter Macdonald, Debra K. Moser, Esther Ang, Glenn Paull, Sam Choucair, John Daly, 

Leila Gholizadeh, and Kathleen Dracup, “Cultural Diversity in Heart Failure Management: Findings from 

the DISCOVER Study (Part 2),” Contemporary Nurse, Vol. 25, No. 1–2, 2007, pp. 50–62. 

Davis, Lois M., Laurie T. Martin, Allen Fremont, Robert Weech-Maldonado, Malcolm V. Williams, and Alice 

Kim, Development of a Long-Term Evaluation Framework for the National Standards for Culturally and 

Linguistically Appropriate Services (CLAS) in Health and Health Care, Washington, D.C.: U.S. Department 

of Health and Human Services, Office of Minority Health, PR-3598-DHHS/OMH, forthcoming. 

DeRosa, Nancy, and Kim Kochurka, “Implement Culturally Competent Healthcare in Your Workplace,” Nursing 

Management, Vol. 37, No. 10, October 2006, pp. 18, 20, 22. 

Diamond, Lisa C., Amy Wilson-Stronks, and Elizabeth A. Jacobs, “Do Hospitals Measure Up to the National 

Culturally and Linguistically Appropriate Services Standards?” Medical Care, Vol. 48, No. 12, December 

2010, pp. 1080–1087. As of November 10, 2017: 

https://www.ncbi.nlm.nih.gov/pubmed/21063229 

Dickson, Victoria Vaughan, Margaret M. McCarthy, Alexandra Howe, Judith Schipper, and Stuart M. Katz, 

“Sociocultural Influences on Heart Failure Self-Care Among an Ethnic Minority Black Population,” Journal 

of Cardiovascular Nursing, Vol. 28, No. 2, 2013, pp. 111–118. 

187 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Diversity Connection, Cultural Competency Assessment Tool for Hospitals (CCATH): Assessing Adherence to the 

CLAS Standards, undated. As of April 18, 2018: 

http://www.diversityconnection.org/diversityconnection/membership/Resource%20Center%20Docs/ 

CCATHOverview.pdf 

Dreachslin, J. L., and F. Hobby, “Racial and Ethnic Disparities: Why Diversity Leadership Matters,” Journal of 

Healthcare Management, Vol. 53, No. 1, January–February 2008, pp. 8–13. 

Evangelista, Lorraine S., Kismet D. Rasmusson, Ann S. Laramee, Joan Barr, Susan E. Ammon, Sandra Dunbar, 

Susan Ziesche, J. Herbert Patterson, and Clyde W. Yancy, “Health Literacy and the Patient with Heart 

Failure—Implications for Patient Care and Research: A Consensus Statement of the Heart Failure Society 

of America,” Journal of Cardiac Failure, Vol. 16, No. 1, 2010, pp. 9–16. 

Federal Register, Executive Order 13166: Improving Access to Services for Persons with Limited English 

Proficiency, Vol. 65, No. 159, August 16, 2000. As of November 10, 2017: 

https://www.gpo.gov/fdsys/pkg/FR-2000-08-16/pdf/00-20938.pdf 

Gertner, Eric J., Judith N. Sabino, Erica T. Mahady, Lynn M. Deitrich, Jarret R. Patton, Mary Kay Grim, James 

F. Geiger, and Debbie Salas-Lopez, “Developing a Culturally Competent Health Network: A Planning 

Framework and Guide,” Journal of Healthcare Management, Vol. 55, No. 3, May–June 2010, pp. 190–204. 

Green, Alexander R., Aswita Tan-McGrory, Marina C. Cervantes, and Joseph R. Betancourt, “Leveraging 

Quality Improvement to Achieve Equity in Health Care,” The Joint Commission Journal on Quality and 

Patient Safety, Vol. 36, No. 10, 2010, pp. 435–442. 

Greenhalgh, Trisha, Glenn Robert, Fraser Macfarlane, Paul Bate, and Olivia Kyriakidou, “Diffusion of 

Innovations in Service Organizations: Systematic Review and Recommendations,” Milbank Quarterly, 

Vol. 82, No. 4, December 2004, pp. 581–629. 

Hasnain-Wynia, Romana, Julie Yonek, Debra Pierce, Ray Kang, and Cynthia Hedges Greising, Hospital 

Language Services for Patients with Limited English Proficiency: Results from a National Survey, Chicago, 

Ill.: The Health Research and Educational Trust, 2006. As of November 10, 2017: 

http://www.hret.org/quality/projects/resources/languageservicesfr.pdf 

188 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Health Indicators Warehouse, Healthcare Effectiveness Data and Information Set (HEDIS), undated. As of 

August 22, 2016: 

http://www.healthindicators.gov/Resources/DataSources/HEDIS_56/Profile 

HealthIT.gov, “How to Implement EHRs: Step 6: Continue Quality Improvement,” webpage, March 20, 2014. 

As of February 14, 2018: 

https://www.healthit.gov/providers-professionals/ehr-implementation-steps/ 

step-6-continue-quality-improvement 

HHS—See U.S. Department of Health and Human Services. 

HHS OMH—See U.S. Department of Health and Human Services, Office of Minority Health. 

Hobgood, Cherri, Susan Sawning, Josie Bowen, and Katherine Savage, “Teaching Culturally Appropriate 

Care: A Review of Educational Models and Methods,” Academic Emergency Medicine, Vol. 13, No. 12, 

December 2006, pp. 1288–1295. 

Hyde, Justeen K., and Stephen M. Shortell, “The Structure and Organization of Local and State Public Health 

Agencies in the U.S.: A Systematic Review,” American Journal of Preventive Medicine, Vol. 42, No. 5, 

2012, pp. S29–S41. 

Institute of Medicine, Health Literacy: A Prescription to End Confusion, Report Brief, April 2004. As of 

November 10, 2017: 

http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2004/ 

Health-Literacy-A-Prescription-to-End-Confusion/healthliteracyfinal.pdf 

The Joint Commission, “Accountability Measures,” undated(a). As of November 10, 2017: 

https://www.jointcommission.org/accountability_measures.aspx 

———, “Behavioral Health Care,” undated(b). As of August 18, 2016: 

https://www.jointcommission.org/accreditation/behavioral_health_care.aspx 

———, Behavioral Health Care Accreditation, Oakbrook Terrace, Ill., 2007. As of November 10, 2017: 

https://www.jointcommission.org/assets/1/18/BHC_Toolkit.pdf 

189 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

———, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A 

Roadmap for Hospitals, Oakbrook Terrace, Ill., 2010. As of November 10, 2017: 

https://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf 

———, A Crosswalk of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in 

Health and Health Care to The Joint Commission Hospital Accreditation Standards, Oakbrook Terrace, Ill., 

July 2014. As of November 10, 2017: 

https://www.jointcommission.org/assets/1/6/Crosswalk-_CLAS_-20140718.pdf 

———, 2016 Accountability Measure List for Accreditation: Chart Abstracted Process Measures, January 2016. 

As of November 10, 2017: 

https://www.jointcommission.org/assets/1/18/accountability_measures_list_2016.pdf 

Joynt, Karen E., E. John Orav, and Ashish K. Jha, “Thirty-Day Readmission Rates for Medicare Beneficiaries by 

Race and Site of Care,” JAMA, Vol. 305, No. 7, February 16, 2011, pp. 675–681. 

Karliner, Leah S., Andrew Auerbach, Anna Nápoles, Dean Schillinger, Dana Nickleach, and Eliseo J. PérezStable, “Language Barriers and Understanding of Hospital Discharge Instructions,” Medical Care, Vol. 50, 

No. 4, 2012. 

Kim-Godwin, Yeoun Soo, Pamela N. Clarke, and Leslie Barton, “A Model for the Delivery of Culturally 

Competent Community Care,” Journal of Advanced Nursing, Vol. 35, No. 6, September 2001, pp. 918–925. 

The Lewin Group, Inc., Indicators of Cultural Competence in Health Care Delivery Organizations: An 

Organizational Cultural Competence Assessment Profile, April 2002. As of November 10, 2017: 

https://www.hrsa.gov/culturalcompetence/healthdlvr.pdf 

Li, Wen-Wen, Anita L. Stewart, Nancy Stotts, and Erika Sivarajan Froelicher, “Cultural Factors Associated with 

Antihypertensive Medication Adherence in Chinese Immigrants,” Journal of Cardiovascular Nursing, 

Vol. 21, No. 5, 2006, pp. 354–362. 

MACPAC—See Medicaid and CHIP Payment and Access Commission. 

190 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Mays, Glen P., Paul K. Halverson, and F. Douglas Scutchfield, “Behind the Curve? What We Know and Need to 

Learn from Public Health Systems Research,” Journal of Public Health Management and Practice, Vol. 9, 

No. 3, 2003, pp. 179–182. 

Medicaid and CHIP Payment and Access Commission, “Chapter 4: Behavioral Health in the Medicaid 

Program—People, Use and Expenditures,” Report to Congress on Medicaid and CHIP, 2015. As of 

November 10, 2017: 

https://www.macpac.gov/wp-content/uploads/2015/06/Behavioral-Health-in-the-MedicaidProgram%E2%80%94People-Use-and-Expenditures.pdf 

Mitchell, Suzanne E., Ekaterina Sadikova, Brian W. Jack, and Michael K. Paasche-Orlow, “Health Literacy 

and 30-Day Postdischarge Hospital Utilization,” Journal of Health Communication, Vol. 17, No. 3, 2012, 

pp. 325–338. 

Mulia, Nina, Tammy W. Tam, and Laura A. Schmidt, “Disparities in the Use and Quality of Alcohol Treatment 

Services and Some Proposed Solutions to Narrow the Gap,” Psychiatric Services, Vol. 65, No. 5, May 1, 

2014, pp. 626–633. 

NACCHO—See National Association of County and City Health Officials. 

National Alliance on Mental Illness, “Mental Health By the Numbers,” webpage, undated. As of March 14, 

2016: 

https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers 

National Association of County and City Health Officials, 2005 National Profile of Local Health Departments, 

Washington, D.C., 2006. As of August 19, 2016: 

http://www.naccho.org/topics/infrastructure/profile/upload/NACCHO_report_final_000.pdf 

———, 2008 National Profile of Local Health Departments, Washington, D.C., July 2009. As of August 19, 

2016: 

http://archived.naccho.org/topics/infrastructure/profile/resources/2008report/upload/ 

NACCHO_2008_ProfileReport_post-to-website-2.pdf 

191 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

———, 2013 National Profile of Local Health Departments, Washington, D.C., January 2014. As of August 19, 

2016: 

http://archived.naccho.org/topics/infrastructure/profile/upload/ 

2013-national-profile-of-local-health-departments-report.pdf 

———, “Mobilizing for Action Through Planning and Partnerships (MAPP),” 2016. As of August 19, 2016: 

http://archived.naccho.org/topics/infrastructure/mapp/ 

National Center for Cultural Competence, A Guide to Infusing Cultural & Linguistic Competence in Health 

Promotion Training: Group Activity—Understanding the Cultural Competence Continuum, Washington, 

D.C.: Georgetown University Center for Child and Human Development, undated. As of November 10, 

2017: 

https://nccc.georgetown.edu/video-infusing-clc/continuum.pdf 

National CLAS Standards Implementation Activities, Rockville, Md.: U.S. Department of Health and Human 

Services, 2016. As of August 19, 2016: 

https://www.thinkculturalhealth.hhs.gov/pdfs/CLASCompendium.pdf 

National Institute of Mental Health, “Minority Health and Mental Health Disparities Program,” webpage, 

undated. As of November 10, 2017: 

http://www.nimh.nih.gov/about/organization/gmh/ 

minority-health-and-mental-health-disparities-program.shtml 

The National Learning Consortium, Continuous Quality Improvement (CQI) Strategies to Optimize Your 

Practice, April 30, 2013. As of November 6, 2017: 

https://www.healthit.gov/sites/default/files/tools/nlc_continuousqualityimprovementprimer.pdf 

National Quality Forum, “NQF Quality Positioning System: NQF Measure Specifications,” webpage, undated. 

As of November 10, 2017: 

http://www.qualityforum.org/QPS/QPSTool.aspx 

192 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

———, National Voluntary Consensus Standards for Ambulatory Care—Measuring Healthcare Disparities, 

Washington, D.C., March 2008. As of November 10, 2017: 

https://www.qualityforum.org/Publications/2008/03/National_Voluntary_Consensus_Standards_for_ 

Ambulatory_Care%E2%80%94Measuring_Healthcare_Disparities.aspx 

———, A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural 

Competency, A Consensus Report, Washington, D.C., 2009. As of November 10, 2017: 

http://www.qualityforum.org/Publications/2009/04/A_Comprehensive_Framework_and_Preferred_ 

Practices_for_Measuring_and_Reporting_Cultural_Competency.aspx 

———, “L1A: Screening for Preferred Spoken Language for Health Care,” Measure Submission and Evaluation 

Worksheet, NQF #1824, January 17, 2012a. As of November 10, 2017: 

http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=70143 

———, “L2: Patients Receiving Language Services Supported by Qualified Language Servcies [sic] Providers,” 

Measure Submission and Evaluation Worksheet, NQF #1821, January 17, 2012b. As of November 10, 2017: 

http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=70142 

———, “Clinician/Group’s Cultural Competence Based on the CAHPS Cultural Competence Item Set,” Measure 

Submission and Evaluation Worksheet, NQF #1904, January 18, 2012c. As of November 10, 2017: 

http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=70154 

———, “Clinician/Group’s Health Literacy Based on the CAHPS Item Set for Addressing Health Literacy,” 

Measure Submission and Evaluation Worksheet, NQF #1902, January 18, 2012d. As of November 10, 2017: 

http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=70154 

———, “Cultural Competency Implementation Measure,” Measure Submission and Evaluation Worksheet, 

NQF #1919, February 20, 2012e. As of November 10, 2017: 

http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=70166 

———, “Endorsement Summary: Healthcare Disparities and Cultural Competency Measures,” August 2012f. 

As of November 10, 2017: 

https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=71695 

193 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

———, Healthcare Disparities and Cultural Competency Consensus Standards: Disparities-Sensitive Measure 

Assessment, Washington D.C., November 15, 2012g. As of November 10, 2017: 

https://www.qualityforum.org/Publications/2012/11/Healthcare_Disparities_and_Cultural_Competency_ 

Consensus_Standards__Disparities-Sensitive_Measure_Assessment.aspx 

New York State Office of Mental Health, “Continuous Quality Improvement (CQI) Initiative for Health 

Promotion and Care Coordination,” undated. As of November 6, 2017: 

https://www.omh.ny.gov/omhweb/psyckes_medicaid/initiatives/freestanding/project_tools/ 

cqi/handbook/cqi-handbook.pdf 

New York State Office of Mental Health, Office of Quality Management, “Quality Improvement Plan,” 2005. 

As of April 17, 2018: 

https://www.doh.wa.gov/Portals/1/Documents/1000/PMC-NY-QI-Plan.pdf 

NIMH—See National Institute of Mental Health. 

NQF—See National Quality Forum. 

Olavarria, Marcela, Julie Beaulac, Alexandre Bélanger, Marta Young, Tim Aubry, “Organizational Cultural 

Competence in Community Health and Social Service Organizations: How to Conduct a Self-Assessment,” 

Journal of Cultural Diversity, Vol. 16, No. 4, Winter 2009, pp. 140–150. 

Powell, Byron J., Thomas J. Waltz, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Monica M. 

Matthieu, Enola K. Proctor, and JoAnn E. Kirchner, “A Refined Compilation of Implementation Strategies: 

Results from the Expert Recommendations for Implementing Change (ERIC) Project,” Implementation 

Science, Vol. 10, No. 21, 2015. As of November 10, 2017: 

https://implementationscience.biomedcentral.com/articles/10.1186/s13012-015-0209-1 

Public Health Accreditation Board, homepage, undated. As of November 10, 2017: 

http://www.phaboard.org/ 

RAND Corporation, “Getting to Outcomes: Improving Community-Based Prevention,” webpage, undated. As 

of November 6, 2017: 

https://www.rand.org/health/projects/getting-to-outcomes.html 

194 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Rodriguez, Fátima, Karen E. Joynt, Lenny López, Fidencio Saldaña, and Ashish K. Jha, “Readmission Rates for 

Hispanic Medicare Beneficiaries with Heart Failure and Acute Myocardial Infarction,” American Heart 

Journal, Vol. 162, No. 2, 2011, pp. 254–261. 

Rural Health Information Hub, “Promotora de Salud/Lay Health Worker Model,” 2011. As of November 10, 

2017: 

https://www.ruralhealthinfo.org/community-health/community-health-workers/2/layhealth 

Saha, Somnath, Mary Catherine Beach, and Lisa A. Cooper, “Patient Centeredness, Cultural Competence and 

Healthcare Quality,” Journal of the National Medical Association, Vol. 100, No. 11, November 2008, 

pp. 1275–1285. 

SAMHSA—See Substance Abuse and Mental Health Services Administration. 

Schwalbe, Leslie, Behavioral Health Providers: Expenditures, Methods and Sources of Payment, Electronic 

Health Record Incentive Payments for Certain Behavioral Health Providers Policy Descriptions, 

Washington, D.C.: U.S. Department of Health and Human Services, Assistant Secretary for Planning and 

Evaluation, Office of Disability, Aging and Long-Term Care Policy, June 30, 2010. As of August 18, 2016: 

https://aspe.hhs.gov/system/files/pdf/76206/behhp.pdf 

Substance Abuse and Mental Health Services Administration, “Grantee Stories, Tools, and Resources,” 

webpage, undated. As of November 6, 2017: 

https://www.samhsa.gov/capt/tools-learning-resources/evaluation-tools-resources 

———, Behavioral Health United States, 2012, Rockville, Md.: Center for Behavioral Health Statistics and 

Quality, 2012. As of August 18, 2016: 

https://www.samhsa.gov/data/sites/default/files/2012-BHUS.pdf 

———, “Appendix C: Tools for Assessing Cultural Competence,” Improving Cultural Competence, Rockville, 

Md., Treatment Improvement Protocol Series No. 59, 2014a. As of November 10, 2017: 

https://www.ncbi.nlm.nih.gov/books/NBK248429/ 

195 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

———, “National Behavioral Health Quality Framework,” webpage, October 30, 2014b. As of November 10, 

2017: 

https://www.samhsa.gov/data/national-behavioral-health-quality-framework#examples 

———, “Applying the Strategic Prevention Framework (SPF): Cultural Competence and the SPF,” webpage, 

September 25, 2015. As of August 18, 2016: 

http://www.samhsa.gov/capt/applying-strategic-prevention-framework/cultural-competence/ 

cultural-competence-spf 

———, “Applying the Strategic Prevention Framework (SPF): Step 5: Evaluate: Process and Outcomes 

Evaluation,” webpage, April 5, 2016a. As of November 10, 2017: 

https://www.samhsa.gov/capt/applying-strategic-prevention-framework/step5-evaluation/ 

process-outcomes-evaluation 

———, “The National CLAS Standards in Action,” webinar, August 4, 2016b. As of November 6, 2017: 

https://www.samhsa.gov/capt/tools-learning-resources/national-clas-standards-action 

———, “Prevention of Substance Abuse and Mental Illness,” webpage, August 9, 2016c. As of August 18, 

2016: 

https://www.samhsa.gov/prevention 

———, “Resources Related to Cultural Competence,” webpage, November 22, 2016d. As of November 10, 

2017: 

https://www.samhsa.gov/capt/tools-learning-resources/resources-related-cultural-competence 

Samnaliev, Mihail, Mark P. McGovern, and Robin E. Clark, “Racial/Ethnic Disparities in Mental Health 

Treatment in Six Medicaid Programs,” Journal of Health Care for the Poor and Underserved, Vol. 20, 

No. 1, 2009, pp. 165–176. 

Sebelius, Kathleen, “Increasing Access to Mental Health Services,” Washington, D.C.: Barack Obama White 

House, April 10, 2013. As of November 10, 2017: 

https://www.whitehouse.gov/blog/2013/04/10/increasing-access-mental-health-services 

196 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

University of Maryland, “Maryland State Legislation for Cultural Competency Training,” undated. As of 

August 19, 2016: 

https://sph.umd.edu/department/epib/cchc/md-legislation-cultural-competency-training 

U.S. Department of Health and Human Services, “HITECH Act Enforcement Interim Final Rule,” undated(a). As 

of August 22, 2016: 

http://www.hhs.gov/hipaa/for-professionals/special-topics/HITECH-act-enforcement-interim-final-rule/ 

index.html 

———, “Think Cultural Health: The Blueprint,” webpage, undated(b). As of November 6, 2017: 

https://www.thinkculturalhealth.hhs.gov/clas/blueprint 

———, “Think Cultural Health: Resource Library,” webpage, undated(c). As of November 6, 2017: 

https://www.thinkculturalhealth.hhs.gov/resources/library 

———, Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the 

Surgeon General, Rockville, Md.: Substance Abuse and Mental Health Services Administration, August 

2001. 

U.S. Department of Health and Human Services, Health Resources and Services Administration, “Quality 

Improvement & Risk Management Training,” webpage, March 31, 2011a. As of April 17, 2018: 

https://www.hrsa.gov/public-health/guidelines/quality-improvement.html 

———, Developing and Implementing a QI Plan, April 2011b. As of November 6, 2017: 

https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/developingqiplan.pdf 

U.S. Department of Health and Human Services, Indian Health Services, “About IHS,” webpage, undated. As 

of November 9, 2017: 

https://www.ihs.gov/aboutihs/ 

U.S. Department of Health and Human Services, Office of Minority Health, “National Partnership for Action 

to End Health Disparities,” homepage, undated. As of November 9, 2017: 

https://minorityhealth.hhs.gov/npa/ 

197 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

———, National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report, 

Washington, D.C., March 2001. As of August 19, 2016: 

https://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf 

———, Developing a Self-Assessment Tool for Culturally and Linguistically Appropriate Services in Local Public 

Health Agencies, December 2003. As of November 6, 2017: 

https://minorityhealth.hhs.gov/assets/pdf/checked/LPHAs_FinalReport.pdf 

———, Evaluation Planning Guidelines for Grant Applicants, Rockville, Md., June 2010. As of November 10, 

2017: 

https://minorityhealth.hhs.gov/Assets/pdf/Checked/1/ 

Evaluation%20Planning%20Guidelines%20for%20Grant%20Applicants.pdf 

———, National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: 

A Blueprint for Advancing and Sustaining CLAS Policy and Practice, Washington, D.C., April 2013. As of 

November 6, 2017: 

https://www.thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedCLASStandardsBlueprint.pdf 

———, National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: 

Compendium of State-Sponsored National CLAS Standards Implementation Activities, Washington, D.C., 

2016. As of April 18, 2018: 

https://www.thinkculturalhealth.hhs.gov/assets/pdfs/CLASCompendium.pdf 

U.S. Department of Health and Human Services, Office of the Surgeon General and National Action Alliance 

for Suicide Prevention, 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action, 

Washington, D.C., September 2012. As of November 9, 2017: 

http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full_report-rev.pdf 

U.S. Department of Justice, Executive Order 13166, Improving Access to Services for Persons with Limited 

English Proficiency, Washington, D.C.: White House, Office of the Press Secretary, August 11, 2000. As of 

August 22, 2016: 

https://www.justice.gov/crt/federal-coordination-and-compliance-section-180 

198 
REFERENCES
 

PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 

Community Needs 

STEP 2: Set Goals and Objectives 

STEP 3: Develop a Logic Model 

STEP 4: Identify Evaluation Research 

Questions 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 

WORKFORCE: Standards 2–4 

COMMUNICATION AND LANGUAGE 

ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

Wang, Philip S., Patricia Berglund, Mark Olfson, Harold A. Pincus, Kenneth B. Wells, and Ronald C. Kessler, 

“Failure and Delay in Initial Treatment Contact After First Onset of Mental Disorders in the National 

Comorbidity Survey Replication,” Archives of General Psychiatry, Vol. 62, No. 6, 2005, pp. 603–613. As of 

November 10, 2017: 

http://dx.doi.org/10.1001/archpsyc.62.6.603 

Weech-Maldonado, Robert, and Sonya B. Merrill, “Building Partnership with the Community: Lessons from the 

Camden Health Improvement Learning Collaborative,” Journal of Healthcare Management, Vol. 45, No. 3, 

2000, pp. 189–205. 

Weech-Maldonado, Robert, Janice L. Dreachslin, Julie Brown, Rohit Pradhan, Kelly L. Rubin, Cameron Schiller, 

and Ron D. Hays, “Cultural Competency Assessment Tool for Hospitals: Evaluating Hospitals’ Adherence 

to the Culturally and Linguistically Appropriate Services Standards,” Health Care Management Review, 

Vol. 37, No. 1, January–March 2012a, pp. 54–66. As of November 10, 2017: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4983191/ 

Weech-Maldonado, Robert, Adam Carle, Beverly Weidmer, Margarita Hurtado, Quyen Ngo-Metzger, and Ron D. 

Hays, “The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Cultural Competence (CC) 

Item Set,” Medical Care, Vol. 50, No. 902, September 2012b, pp. S22–S31. As of November 10, 2017: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748811/ 

Weech-Maldonado, Robert, Marc N. Elliott, Rohit Pradhan, Cameron Schiller, Janice Dreachslin, and Ron D. Hays, 

“Moving Towards Culturally Competent Health Systems: Organizational and Market Factors,” Social Science 

Medicine, Vol. 75, No. 5, September 2012c, pp. 815–822. 

Weiner, Bryan J., Jeffrey A. Alexander, Stephen M. Shortell, Laurence C. Baker, Mark Becker, and Jeffrey J. 

Geppert, “Quality Improvement Implementation and Hospital Performance on Quality Indicators,” Health 

Services Research, Vol. 41, No. 2, April 2006, pp. 307–334. 

199 
PREFACE 

SUMMARY 

CHAPTER 1 

About the Toolkit 

Importance of Evaluating the National CLAS 

Standards 

What This Toolkit Is Designed to Do 

Who Should Use This Toolkit? 

How the Toolkit Is Organized 

CHAPTER 2 

Getting Started 

STEP 1: Assess Organizational and 


Community Needs
 

STEP 2: Set Goals and Objectives
 

STEP 3: Develop a Logic Model
 

STEP 4: Identify Evaluation Research 


Questions
 

STEP 5: Choose Measures 

STEP 6: Design Evaluation and Collect Data 

STEP 7: Share Findings and Make Changes as 

Part of CQI 

CHAPTER 3 

Tips for Evaluating the National 

CLAS Standards 

PRINCIPAL STANDARD: Standard 1 

GOVERNANCE, LEADERSHIP, AND 


WORKFORCE: Standards 2–4 


COMMUNICATION AND LANGUAGE 


ASSISTANCE: Standards 5–8 

ENGAGEMENT, CONTINUOUS 

IMPROVEMENT, AND ACCOUNTABILITY: 

Standards 9–15 

CHAPTER 4 

Evaluation Resources 

APPENDIX A 

Ambulatory Care Setting 

APPENDIX B 

Behavioral Health Setting 

APPENDIX C 

Hospital Setting 

APPENDIX D 

Public Health Setting 

APPENDIX E 

Cross-Cutting Measures 

REFERENCES 

REFERENCES
 

Weissman, Joel S., Joseph R. Betancourt, Alexander R. Green, Gregg S. Meyer, Aswita Tan-McGrory, Jacob D. 

Nudel, Jessica A. Zeidman, and J. Emilio Carrillo, Commissioned Paper: Healthcare Disparities Measurement, 

Washington, D.C.: National Quality Forum, February 2012. As of November 10, 2017: 

http://www.qualityforum.org/Publications/2012/02/Commissioned_Paper__Healthcare_Disparities_ 

Measurement.aspx 

Wholey, Douglas R., Walter Gregg, and Ira Moscovice, “Public Health Systems: A Social Networks Perspective,” 

Health Services Research, Vol. 44, No. 5, Part 2, 2009, pp. 1842–1862. 

Wilson-Stronks, Amy, and Erica Galvez, Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A 

Report of Findings, Oakbrook Terrace, Ill.: Joint Commission on Accreditation of Healthcare Organizations, 

2007. 

Wiseman, Shelley H., Matthew Chinman, Patricia A. Ebener, Sarah B. Hunter, Pamela Imm, and Abraham 

Wandersman, Getting To Outcomes: 10 Steps for Achieving Results-Based Accountability, Santa Monica, 

Calif.: RAND Corporation, TR-101/2-CDC, 2007. As of October 31, 2017: 

https://www.rand.org/pubs/technical_reports/TR101z2.html 

World Health Organization, Constitution of the World Health Organization, Geneva, Switzerland, 1946. As of 

November 9, 2017: 

http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf?ua=1 

200