Development of a Long-Term 

Evaluation Framework for the 

National Standards for Culturally 

and Linguistically Appropriate 

Services (CLAS) in Health and 

Health Care

Lois M. Davis, Laurie T. Martin, Allen Fremont, 

Robert Weech-Maldonado, Malcolm V. Williams, Alice Kim

PR-3598-DHHS/OMH
 

PR-3598-DHHS/OMH

Development of a Long-Term Evaluation Framework for the National Standards for Culturally and 


Linguistically Appropriate Services (CLAS) in Health and Health Care
 

© Copyright 2018 RAND Corporation 

R® is a registered trademark. 

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

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Support RAND 

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www.rand.org 
 

 

 

 

 

 

 

 

 

 

 

 

 

Preface
 

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 it may also reduce disparities experienced by racial and ethnic minorities and other 

underserved populations who face language, literacy, or other cultural barriers. To provide 

meaningful and practical guidance on delivering culturally and linguistically appropriate services 

to health organizations and health care organizations (HCOs), the U.S. Department of Health and 

Human Services (HHS) Office of Minority Health (OMH), in collaboration with federal and 

nonfederal partners across the country, 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 organizations and 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. Central to this effort was the 

recognition of the need for a long-term evaluation framework for assessing the implementation 

of the National CLAS Standards. 

RAND was awarded a contract by HHS OMH to develop the long-term evaluation 

framework for the National CLAS Standards. This report presents the details of the development 

of the framework, while the accompanying RAND toolkit titled Evaluation of the National CLAS 

Standards: Tips and Resources (PR-3599-DHHS/OMH, Williams et al., 2018) 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. 

RAND Health 

This work was sponsored by HHS OMH 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. 

iii 
 

 

Contents
 

Preface............................................................................................................................................iii
 

Figures............................................................................................................................................ vi
 

Tables............................................................................................................................................ vii
 

Summary......................................................................................................................................viii
 

Acknowledgments....................................................................................................................... xvii
 

Abbreviations............................................................................................................................. xviii
 

Chapter One. Introduction .............................................................................................................. 1
 

The National CLAS Standards ..................................................................................................................2
 

Governance, Leadership, and Workforce..............................................................................................2
 

Communication and Language Assistance ...........................................................................................2
 

Engagement, Continuous Improvement, and Accountability ...............................................................2
 

Project Goals .............................................................................................................................................3
 

Approach ...................................................................................................................................................4
 

Technical Advisory Group....................................................................................................................4
 

Development of the Conceptual Framework and Logic Models ..........................................................4
 

Development of Evaluation Questions and Measures ..........................................................................5
 

Organization of This Report......................................................................................................................5
 

Chapter Two. Conceptual Framework............................................................................................ 7
 

Diffusion Within the Health Organization ................................................................................................8
 

Antecedents and Inputs .........................................................................................................................8
 

Readiness for the National CLAS Standards ........................................................................................9
 

Development of Implementation Strategies and Communication ......................................................10
 

Adoption/Implementation ...................................................................................................................11
 

Outputs and Outcomes ........................................................................................................................12
 

Quality Improvement ..........................................................................................................................13
 

Linkages with the Community and Other Stakeholders..........................................................................13
 

Environmental and Policy Context .........................................................................................................14
 

Conclusion...............................................................................................................................................15
 

Chapter Three. Ambulatory Care Logic Model ............................................................................ 16
 

Logic Model for Implementing the National CLAS Standards Within the Ambulatory Care Setting ...18
 

Context, Antecedents, and Inputs........................................................................................................18
 

National CLAS Standards ...................................................................................................................22
 

Proposed Changes and Strategies Developed to Implement Those Changes .....................................22
 

Outputs ................................................................................................................................................23
 

Outcomes.............................................................................................................................................24
 

Quality Improvement ..........................................................................................................................25
 

Chapter Four. Hospital Logic Model ............................................................................................ 26
 

iv 
Logic Model for Implementation of the National CLAS Standards Within the Hospital Setting ..........28
 

Context, Antecedents, and Inputs........................................................................................................28
 

National CLAS Standards ...................................................................................................................32
 

Proposed Changes and Strategies Developed to Implement Those Changes .....................................32
 

Outputs ................................................................................................................................................33
 

Outcomes.............................................................................................................................................33
 

Quality Improvement ..........................................................................................................................34
 

Chapter Five. Behavioral Health Logic Model............................................................................. 35
 

Logic Model for Implementation of the National CLAS Standards Within the Behavioral Health
 

Setting...............................................................................................................................................36
 

Context, Antecedents, and Inputs........................................................................................................36
 

National CLAS Standards ...................................................................................................................41
 

Proposed Changes and Strategies Developed to Implement Those Changes .....................................41
 

Outputs ................................................................................................................................................41
 

Outcomes.............................................................................................................................................42
 

Quality Improvement ..........................................................................................................................43
 

Chapter Six. Public Health Logic Model...................................................................................... 44
 

Logic Model for Implementation of the National CLAS Standards Within the Public Health
 

Setting...............................................................................................................................................45
 

Context, Antecedents, and Inputs........................................................................................................47
 

National CLAS Standards ...................................................................................................................50
 

Proposed Changes and Strategies Developed to Implement Those Changes .....................................50
 

Outputs ................................................................................................................................................51
 

Outcomes.............................................................................................................................................51
 

Quality Improvement ..........................................................................................................................52
 

Chapter Seven. Evaluation Questions and Impact Measures........................................................ 54
 

Evaluation Questions...............................................................................................................................55
 

Process Evaluation Questions .............................................................................................................56
 

Outcomes Evaluation Questions .........................................................................................................57
 

Measures..................................................................................................................................................59
 

Approach .............................................................................................................................................59
 

Measures Identified.............................................................................................................................60
 

Chapter Eight. Conclusions .......................................................................................................... 67
 

Appendix A. List of Technical Advisory Group Members .......................................................... 69
 

Appendix B. Cross-Cutting Measures .......................................................................................... 70
 

Appendix C. Ambulatory Care Measures ..................................................................................... 83
 

Appendix D. Hospital Measures ................................................................................................... 88
 

Appendix E. Behavioral Health Measures.................................................................................... 97
 

Appendix F. Public Health Measures ......................................................................................... 101
 

References................................................................................................................................... 108
 

v 
 

 

 

 

 

Figures
 

Figure S.1. Conceptual Framework for Evaluating the National CLAS Standards........................ x
 

Figure S.2. Logic Model for Implementation of the National CLAS Standards Within the
 

Ambulatory Care Setting ....................................................................................................... xi
 

Figure 2.1. Conceptual Framework for the Diffusion of the National CLAS Standards................ 8
 

Figure 3.1. Logic Model for Implementation of the National CLAS Standards Within the
 

Ambulatory Care Setting ...................................................................................................... 19
 

Figure 4.1. Logic Model for Implementation of the National CLAS Standards Within the
 

Hospital Setting..................................................................................................................... 30
 

Figure 5.1. Logic Model for Implementation of the National CLAS Standards Within the
 

Behavioral Health Setting ..................................................................................................... 38
 

Figure 6.1. Logic Model for Implementation of the National CLAS Standards Within the
 

Public Health Setting ............................................................................................................ 46
 

vi 
Tables
 

Table S.1. Cross-Cutting Measures .............................................................................................. xv
 

Table 6.1. Linking the National CLAS Standards to Core Public Health Department
 

Functions............................................................................................................................... 44
 

Table 6.2. Diverse LHD Organizational Arrangements ............................................................... 45
 

Table 7.1. Cross-Cutting Measures............................................................................................... 61
 

Table 7.2. Ambulatory Care Measures ......................................................................................... 62
 

Table 7.3. Hospital Measures........................................................................................................ 63
 

Table 7.4. Behavioral Health Measures ........................................................................................ 65
 

Table 7.5. Public Health Measures ............................................................................................... 66
 

Table B.1. Cross-Cutting Measures .............................................................................................. 71
 

Table B.2. Cross-Cutting Measures: Additional Details .............................................................. 73
 

Table C.1. Ambulatory Care Measures......................................................................................... 83
 

Table C.2. Ambulatory Care Measures: Additional Details ......................................................... 86
 

Table D.1. Hospital Measures....................................................................................................... 88
 

Table D.2. Hospital Measures: Additional Details ....................................................................... 92
 

Table E.1. Behavioral Health Measures ....................................................................................... 97
 

Table E.2. Behavioral Health Measures: Additional Details........................................................ 99
 

Table F.1. Public Health Measures ............................................................................................. 101
 

Table F.2. Public Health Measures: Additional Details ............................................................. 104
 

vii 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 it may also reduce disparities experienced by racial and ethnic minorities and other 

underserved populations who face 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), in collaboration with federal and nonfederal partners across 

the country, 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 organizations 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). 

Central to this effort was the recognition of the need for a long-term evaluation framework for 

health organizations and HCOs that are implementing the National CLAS Standards. The 

evaluation framework was designed to provide a systematic approach to gathering data to 

evaluate the effectiveness of the National CLAS Standards through three key objectives: (1) 

describing the National CLAS Standards theory of change, (2) developing evaluation questions 

that test the theory of change and their corresponding methods, and (3) developing indicators and 

supporting data metrics to support the National CLAS Standards theory of change.

1 

1 The terms indicators and measures can be used interchangeably. In this report, we chose to use the term measure 

to be inclusive of the wide range of different types of measures, from the Consumer Assessment of Healthcare 

Providers and Systems (CAHPS) measures to such disparity-sensitive clinical measures as median time to 

electrocardiogram (ECG). 

The RAND Corporation was awarded a contract by HHS OMH to develop a long-term 

evaluation framework for the National CLAS Standards to help health organizations and HCOs 

assess the impact that implementation of the National CLAS Standards has both on the quality of 

care and services provided and on patient outcomes. RAND convened a technical advisory group 

(TAG) to inform the development of key elements of this evaluation framework, including an 

overarching conceptual framework and setting-specific logic models, evaluation questions, and 

process and impact measures. 

viii 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Conceptual Framework for Evaluating the National CLAS Standards 

In the conceptual framework shown in Figure S.1, the National CLAS Standards represent 

the innovation to be adopted by a health organization. Although the National CLAS Standards 

were published by HHS OMH, they were developed in conjunction with a wide range of 

community stakeholders. These stakeholders and community members have witnessed or 

experienced situations in which culturally and linguistically appropriate care and services were 

not present, provided feedback and input on current gaps, and helped inform and shape a set of 

National CLAS Standards that addressed many of these concerns. 

Whether and how readily an organization is willing and able to adopt the National CLAS 

Standards depend on a number of factors relevant to the National CLAS Standards themselves. 

These factors include the organization’s understanding of the National CLAS Standards, the 

availability of guidelines and examples of best practices, and the perceived relative advantage to 

the organization of implementing the National CLAS Standards. Organizations will also assess 

how compatible the National CLAS Standards are with current organizational goals, practices, 

and other regulations or guidelines they must follow, as well as how easy or hard they are to 

understand and adopt into practice. 

The conceptual framework shown in Figure S.1 describes the diffusion of the National CLAS 

Standards within a given health organization, including organization-specific antecedents and 

inputs; readiness for adopting the National CLAS Standards; activities related to the adoption, 

assimilation, and diffusion of the National CLAS Standards, such as strategies for 

implementation; and communication about those activities, the implementation of the activities, 

and outputs and outcomes for both internal and external audiences. 

ix 
 

 

 

 

 

 

 

 

 

Figure S.1. Conceptual Framework for Evaluating the National CLAS Standards 

Setting-Specific Logic Models 

Based on the conceptual framework, we developed logic models for the four settings that are 

the focus of this study: ambulatory care, hospitals, behavioral health, and public health. The logic 

model for ambulatory care is illustrated in Figure S.2. For each logic model, we first discuss the 

relevance of the National CLAS Standards to each setting, including relevant linkages with the 

community and other stakeholders. The logic model itself includes the context, antecedents, and 

inputs; proposed changes and strategies to implement those changes; outputs; and short-term and 

longer-term outcomes at the organizational and client levels. We also depict the adoption and 

implementation of the National CLAS Standards as a continual process, requiring a quality 

improvement (QI) loop in which outputs and outcomes inform the development of future 

ambulatory care settings (ACS) actions, policies, or programs to better align with the National 

CLAS Standards. 

x 
 xi
 

Figure S.2. Logic Model for Implementation of the National CLAS Standards Within the Ambulatory Care Setting 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evaluation Questions 

We derived evaluation questions from the conceptual framework and logic models that 

address the process of an organization deciding to implement the National CLAS Standards, the 

planning for and implementation of activities to do so, and the resulting outputs, as well as key 

outcomes to measure. We identified the overarching process and outcomes evaluation questions 

and detailed a subset of related questions for each overarching question. 

The overarching process evaluation questions include: 

1.	 Is there an awareness of the National CLAS Standards? 

2.	 Does the organization have a team tasked with addressing culture and language? 

3.	 Does the organization have active and ongoing input from the community? 

4.	 Has the organization completed a needs assessment with respect to the National CLAS 

Standards? 

5.	 Has the organization developed an implementation plan to address identified gaps and 

priorities? 

6.	 Has the organization committed funds or resources for the proposed change? 

7.	 To what extent has the organization implemented its plan to address identified needs and 

gaps in culturally and linguistically appropriate services? 

8.	 To what extent does the organization collect and use data for continuous quality
 

improvement (CQI)?
 

The overarching outcomes evaluation questions are grouped by short-term and longer-term 

outcomes. 

Short-Term Outcomes 

For organizations: To what extent has the implementation of the National CLAS Standards 

led or contributed to 

•	 use of data on race, ethnicity, sex, sexual orientation, 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 or 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 more-informed 

care decisions? 

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

xii 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Longer-Term Outcomes 

For organizations: To what extent has the implementation of the National CLAS Standards 

led to a cultural shift in the organization? To what extent has implementation led to or 

contributed to 

•	 improvements in the provision of high-quality 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? 

•	 reductions in disparities in health outcomes? 

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

population?
 

For clients or individuals: To what extent has the 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 contributed to 

•	 increased use of appropriate health care services with regular follow-up and continuing of 

care? 

•	 increased equity in outcomes of health services? 

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

Measures 

The overarching goal of the National CLAS Standards is to “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” (Principal Standard [Standard 1] in HHS OMH, 2013). It is important to place the 

National CLAS Standards in the context of ongoing trends in the health care field. Increasing 

emphasis on outcomes of care, patient experience, and value-based care, along with increasingly 

diverse patient populations, mean that for most HCOs, examining quality scores for their overall 

population served will no longer be sufficient. HCOs will also need to assess whether and how 

those quality scores differ between patients or clients belonging to different racial/ethnic groups 

or different language groups. Ideally, where gaps are found, HCOs will develop QI interventions 

to reduce gaps and track improvements over time. 

As such, our emphasis was on salient measures that can be quantified, compared between 

patient and client subgroups, and/or compared over time. Most of the identified measures are 

xiii 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

based on survey questions, such as CAHPS survey items, or on electronic medical records 

(EMRs) and claims data. Each HCO may differ with respect to the type of measure or measures 

that are most applicable and useful to its CLAS efforts. 

Our goal was to identify a range of examples for each health care setting, emphasizing wellconstructed and validated measures with some or all of the following characteristics: 

• assessed cultural competency 

• captured language needs or preferences and/or were linked to other CLAS-related issues 

• documented disparities 

• were widely used and plausible for use in a range of HCOs (e.g., small or large) 

− were inclusive of measures that are used by several different quality reporting 

systems (e.g., sets of measures used by the Health Resources and Services 

Administration, National Committee for Quality Assurance, and Centers for Medicare 

& Medicaid Services [CMS]) 

• were previously endorsed in commissioned projects or reports for evaluating disparities 

• were validated and/or psychometrically tested 

• include cross-cutting measures across conditions and/or across settings. 

Although we included some process measures, our focus was on identifying outcome and 

impact measures relevant to evaluating the implementation of the National CLAS Standards. 

Wherever possible, we also sought to identify measures of short-term or intermediate outcomes 

of health care encounters with the HCO to facilitate more-rapid feedback on whether the CLASrelated policies and practices put in place have helped to achieve the desired outcomes. This 

includes, for example, clinical outcomes, such as blood pressure control, or a patient’s reported 

experience with care, such as whether the patient felt that he or she was treated unfairly at the 

provider’s office because of cultural (e.g., sexual orientation or gender identity, immigrant status, 

race) or language differences. In addition, we sought to identify examples of disparity-sensitive 

measures for each setting that might help an HCO assess how well it is doing in addressing 

identified disparities in outcomes. Rather than being comprehensive, the set of measures 

identified is intended to illustrate which key outcome and impact measures are salient to the 

National CLAS Standards. The measures are categorized as cross-cutting (i.e., measures that are 

applicable to a range of settings) and setting-specific for ambulatory care, hospitals, behavioral 

health, and public health. 

Table S.1 provides a summary of the cross-cutting measures identified. The setting-specific 

measures are provided in Chapter Seven. 

xiv 
 

Table S.1. Cross-Cutting Measures 

Measure(s) Description 

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 CAHPS Clinician/Group Survey that 

includes the following domains: patient-provider communication; 

complementary and alternative medicine; experiences of discrimination due 

to race/ethnicity, insurance, or language; experiences leading to trust or 

distrust, including level of trust, caring, and confidence in the truthfulness of 

a 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. 

Clinician/group’s 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 CAHPS Clinician/Group 

Survey. 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. 

Patients receiving language services 

supported by qualified language services 

providers 

This measure is used to assess the percentage of patients with limited 

English proficiency 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. 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. 

Screening for preferred spoken language 

for health care 

This measure is used to assess the percentage of patient visits and 

admissions in which the 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 in which they prefer to receive 

care and the extent to which this information is recorded. 

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 National Quality 

Forum–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. 

xv 
Measure(s) Description 

 

 

 

 

 

 

 

 

 

Communication Climate Assessment 

Toolkit (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 

complements CAHPS assessments, documents compliance with Title VI 

(CLAS) standards, and is invaluable in meeting the patient-centered 

communication standards of the Joint Commission on Accreditation of 

Healthcare Organizations. 

Conclusions 

The National CLAS Standards call attention to 15 areas that, if addressed, hold great promise 

for helping health organizations and HCOs address current barriers to providing equitable care. 

The OMH also recognized the importance of establishing an evaluation framework to guide 

long-term efforts to assess the implementation of the National CLAS Standards. The evaluation 

framework, logic models, and evaluation questions and measures presented in this report are 

intended to provide a systematic approach for gathering data to evaluate the effectiveness of the 

National CLAS Standards. 

In addition, we have developed a companion toolkit titled Evaluation of the National CLAS 

Standards: Tips and Resources (Williams et al., forthcoming). The interactive toolkit is designed 

to support health organizations in their efforts to implement the National CLAS Standards and to 

improve their capacity to evaluate their approach. By providing a conceptual framework and 

logic models, evaluation questions, and measures that are already widely collected in practice, 

health organizations can more easily assess the impact of their efforts, both on the individuals 

they serve and on their organizations. Such evaluations can not only provide valuable data and 

insights that inform CQI efforts within a given health organization but collectively can inform 

and help to shape systems-level change toward providing culturally and linguistically appropriate 

care and services. 

xvi 
 

 

 

 

 

 

 

Acknowledgments
 

We wish to express our sincere appreciation to the members of the technical advisory group 

who provided input on the development of the conceptual framework and logic models or 

theories of change. They include 

•	 Margo L. Bailey, Ph.D., M.P.A., HHS 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, NewYorkPresbyterian 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, CMS 

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

of Health Equity 

•	 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. 

We also are grateful for the valuable feedback and guidance provided by OMH deputy 

director Carol Jimenez, J.D.; Andrew Sanderson, M.D.; Dianne Rucinski, Ph.D.; Alexis D. 

Bakos, Ph.D.; former director J. Nadine Gracia; and Christine Montgomery. 

In addition, we appreciate the research support provided by our RAND colleague Rachel 

Ross. Lastly, we wish to thank Gayle Tang from our technical advisory group and Matthew 

Chinman of RAND for their careful review of this document. 

xvii 
 

 

Abbreviations
 

ACA Affordable Care Act 

ACO accountable care organization 

ACS ambulatory care setting 

AHA American Hospital Association 

AHCM Accountable Health Communities Model 

AHRQ Agency for Healthcare Research and Quality 

AMI acute myocardial infarction 

APA American Psychological Association 

CABG coronary artery bypass graft 

CAHPS Consumer Assessment of Healthcare Providers and Systems 

C-CAT Communication Climate Assessment Toolkit 

CCATH Cultural Competency Assessment Tool for Hospitals 

CDC Centers for Disease Control and Prevention 

CDPH California Department of Public Health 

CHNA community health needs assessment 

CLAS culturally and linguistically appropriate services 

CMS Centers for Medicare & Medicaid Services 

COPD chronic obstructive pulmonary disease 

CQI continuous quality improvement 

EMR electronic medical record 

FQHC Federally Qualified Health Center 

HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems 

HCO health care organization 

HEDIS Healthcare Effectiveness Data and Information Set 

HF heart failure 

HHS U.S. Department of Health and Human Services 

xviii 
HIT health information technology 

HITECH Act Health Information Technology for Economic and Clinical Health Act 

HRSA Health Resources and Services Administration 

IFD Institute for Diversity in Health Management 

JCAHO Joint Commission on Accreditation of Healthcare Organizations

LEP limited English proficiency 

LHD local health department 

MBHO managed behavioral health care organizations 

MHPA Mental Health Parity Act of 1996 

MHPAEA Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

NACCHO National Association of County and City Health Officials 

National CLAS 

Standards 

National Standards for Culturally and Linguistically Appropriate 

Services in Health and Health Care 

NCQA National Committee for Quality Assurance 

NIMH National Institute of Mental Health 

OMH Office of Minority Health 

PCI percutaneous coronary intervention 

POA present on admission 

QI quality improvement 

RSRR risk-standardized readmission rate 

SAMHSA Substance Abuse and Mental Health Services Administration 

SCHIP State Children’s Health Insurance Program 

SES socioeconomic status 

SPF Strategic Prevention Framework 

TAG technical advisory group 

THA total hip arthroplasty 

TKA total knee arthroplasty 

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Chapter One. Introduction
 

Cultural competency is achieved through learning processes, structures, and policies by 

which organizations and individuals develop the attitudes, behaviors, and systems needed for 

effective cross-cultural interactions, including, but not limited to, such sociocultural factors as 

race/ethnicity, nationality, language, gender, socioeconomic status (SES), immigrant status, 

physical and mental ability, sexual orientation, religion, health literacy, age, and occupation 

(Betancourt et al., 2003). Culture is central in delivering health care services because it can 

influence patients’ health beliefs, medical practices, attitudes toward medical care, and levels of 

trust (U.S. Department of Health and Human Services [HHS], 2001). Cultural and language 

differences can affect how health information is received, understood, and acted on (Anderson et 

al., 2003). Clinical barriers occur when cultural and language differences are not adequately 

addressed in health care delivery, leading to lower access and quality of care for culturally 

diverse populations. 

“Health equity is the attainment of the highest level of health for all people” (HHS Office of 

Minority Health [OMH], undated). Health inequities result in disparities that affect quality of 

life, neighborhoods, communities, and the broader society (HHS OMH, 2013). A number of 

factors affect health equity, including SES, education level, and the availability of health services 

(HHS Office of Disease Prevention and Health Promotion, undated), with health inequities being 

directly related to the existence of historical and current discrimination and social injustice (HHS 

OMH, 2013). Despite multiple public- and private-sector initiatives to address health inequities 

and disparities in access to health and health care, progress has been slow, and problems with 

equity and disparities persist. Among the many factors related to health inequities, a lack of 

culturally and linguistically appropriate services has been recognized as one of the more 

modifiable factors (Saha, Beach, and Cooper, 2008). Improving the availability of such services 

will not only improve the quality of care received but may also reduce the resulting disparities 

experienced by racial and ethnic minorities and other underserved populations. 

To provide meaningful and practical guidance to health organizations and health care 

organizations (HCOs), HHS OMH, in collaboration with federal and nonfederal partners across 

the country, developed the National Standards for Culturally and Linguistically Appropriate 

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

delivering culturally and linguistically appropriate services to improve quality, advance health 

equity, and help eliminate health disparities. The original National CLAS Standards were 

intended to provide guidance on cultural and linguistic competency, with the goal of ultimately 

reducing racial and ethnic health care disparities (HHS OMH, 2013). From 2010 to 2012, OMH 

launched the National CLAS Standards Enhancement Initiative to update and revise the National 

CLAS Standards to account for the increasing diversity of the U.S. population, the growth in 

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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). 

The resulting 15 National CLAS Standards “are intended to advance health equity, improve 

quality, and help eliminate health care disparities” (HHS OMH, 2013). 

The National CLAS Standards 

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

The remaining 14 National CLAS Standards are listed below and span the themes of 

governance, leadership, and workforce; communication and language assistance; and 

engagement, continuous improvement, and accountability. 

Governance, Leadership, and Workforce 

2.	 Advance and sustain organizational governance and leadership that promotes CLAS and 

health equity through policy, practices, and allocated resources. 

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

leadership, and workforce that are responsive to the populations in the service area. 

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

appropriate policies and practices on an ongoing basis. 

Communication and Language Assistance 

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

other communication needs, at no cost to them, to facilitate timely access to all health 

care and services. 

6.	 Inform all individuals of the availability of language assistance services clearly and in 

their preferred language, verbally and in writing. 

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

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

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

commonly used by the populations in the service area. 

Engagement, Continuous Improvement, and Accountability 

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

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

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

CLAS-related measures into measurement and continuous quality improvement 

activities. 

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11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the 

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

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

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

populations in the service area. 

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

services to ensure cultural and linguistic appropriateness. 

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

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

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

stakeholders, constituents, and the general public. 

The revised National CLAS Standards incorporated broader definitions of culture and health 

and were intended to reach a wide audience, with the goal of ensuring that every individual has 

the opportunity to receive culturally and linguistically appropriate health care and services. 

Specifically, OMH put forth the following definitions in its 2013 Blueprint for Advancing and 

Sustaining CLAS Policy and Practice (HHS OMH, 2013): 

Culture is defined as the integrated pattern of thoughts, communications, actions, 

customs, beliefs, values, and institutions associated, wholly or partially, with 

racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, 

geographical, or sociological characteristics. Culture is dynamic in nature, and 

individuals may identify with multiple cultures over the course of their lifetimes. 

Health is understood to encompass many aspects, including physical, mental, 

social, and spiritual well-being (HHS Indian Health Service, undated; HHS 

Office of the Surgeon General and National Action Alliance for Suicide 

Prevention, 2012; World Health Organization [WHO], 1946). The World Health 

Organization also notes that health is “not merely the absence of disease or 

infirmity” (WHO, 1946). Health status occurs along a continuum and therefore 

can range from poor to excellent. The advancement of health equity allows 

individuals to experience better health over the course of their life spans. 

Audience: The [revised] National CLAS Standards reference both health and 

health care organizations to acknowledge those working not only in health care 

settings, such as hospitals, clinics, and community health centers, but also in 

organizations that provide services such as behavioral and mental health, public 

health, emergency services, and community health. Any organization addressing 

individual or community health, health care, or well-being can benefit from the 

adoption and implementation of the National CLAS Standards. 

Project Goals 

In its 2013 Blueprint (HHS OMH, 2013), OMH recognized that implementation of the 

National CLAS Standards would vary from HCO to HCO and would depend on the 

organization’s size, mission, scope, and type of services offered. OMH also recognized the need 

to establish an evaluation framework to guide long-term efforts to assess the implementation of 

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the National CLAS Standards—to describe the National CLAS Standards’ adoption and 

implementation and examine the relationship between the National CLAS Standards’ 

implementation and their associated outcomes, including advancing health equity, improving 

quality, and eliminating health care disparities. The evaluation framework was created to provide 

a systematic approach to gathering data to evaluate the effectiveness of the National CLAS 

Standards through three key objectives: (1) describe the National CLAS Standards theory of 

change, (2) develop evaluation questions that test the theory of change and the corresponding 

methods, and (3) develop indicators2 

2 The terms indicators and measures can be used interchangeably. In this report, we chose to use the term measure 

to be inclusive of the wide range of types of measures, from the Consumer Assessment of Healthcare Providers and 

Systems (CAHPS) measures to such disparity-sensitive clinical measures as median time to electrocardiogram 

(ECG). 

and supporting data metrics to support the National CLAS 

Standards theory of change. In 2016, through a competitive bidding process, OMH awarded the 

RAND Corporation a contract to develop that evaluation framework. 

Approach 

Technical Advisory Group 

To help guide the development of the evaluation framework, we formed a technical advisory 

group (TAG). For a full list of TAG members, see Appendix A. The TAG included diverse 

representation from experts in language and culture, diversity and equity, evaluation, direct 

service provision, and each of the health care settings prioritized by the project (ambulatory care, 

hospitals, behavioral health, and public health). In addition, we sought a balance of 

representatives from federal and nonfederal organizations. 

Development of the Conceptual Framework and Logic Models 

To develop the conceptual framework, we adapted an existing model by Greenhalgh et al. 

(2004) that focused on the diffusion of innovations in HCOs. The resulting framework 

conceptualizes the National CLAS Standards as an innovation to be adopted within health care 

settings; describes the inputs, activities, outputs, and outcomes occurring within an HCO; and 

illustrates how the National CLAS Standards may be implemented and adopted. 

We then developed setting-specific logic models, drawing from literature reviews as well as 

feedback from our TAG. Given the wide range of changes that could be made within an HCO in 

response to implementing the National CLAS Standards, we decided to keep the logic models at 

a somewhat high level, with the intent that HCOs would use these as a starting point for their 

own evaluation, providing richer detail specific to their setting. 

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Development of Evaluation Questions and Measures 

The evaluation questions were designed to capture key elements of the logic models and to 

address both the process of implementing the National CLAS Standards and the relevant outputs 

and outcomes. The final set of evaluation questions is relevant across a range of HCOs. 

To identify the set of process and impact measures, we conducted a review of the literature 

and reviewed a wide range of existing surveys and data-collection instruments already used by 

HCOs to report on patient experience, quality of care, and health outcomes. This also included a 

review of data routinely collected within electronic medical records (EMRs) and claims data. 

Our emphasis was on the identification of salient measures that can be quantified, compared 

between patient and client subgroups, and/or compared over time. We also sought to identify a 

range of examples for each health care setting, emphasizing well-constructed and validated 

measures with some or all of the following characteristics: 

• assessed cultural competency 

• captured language needs or preferences and/or were linked to other CLAS-related issues 

• documented disparities 

• were widely used and plausible for use in a range of HCOs (e.g., small or large) 

− were inclusive of measures that are used by several different quality reporting 

systems (e.g., sets of measures used by the Health Resources and Services 

Administration [HRSA], National Committee for Quality Assurance [NCQA], and 

Centers for Medicare & Medicaid Services [CMS]) 

• were previously endorsed in commissioned projects or reports for evaluating disparities 

• were validated and/or psychometrically tested 

• included cross-cutting measures across conditions and/or across settings. 

The list of measures included in this report is not intended to be exhaustive, but to provide 

helpful examples of the types of measures HCOs might use to capture the implementation and 

impact of their specific changes. The toolkit accompanying this report, titled Evaluation of the 

Implementation of the National CLAS Standards: Tips and Resources (Williams et al., 

forthcoming), distills the elements of the evaluation framework and is intended to help guide the 

efforts of HCOs to evaluate the implementation of the National CLAS Standards within their 

own setting. 

Organization of This Report 

The remainder of this report provides additional information on the evaluation framework for 

the National CLAS Standards. Chapter Two presents the conceptual framework, while Chapters 

Three through Six present the individual logic models for each of the four settings prioritized in 

this study (ambulatory care, hospitals, behavioral health, and public health). The logic model 

summaries are stand-alone chapters for those readers who may be interested in a particular type 

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of setting. Because the logic model chapters are meant to stand alone, some text is repeated in 

these chapters. Chapter Seven summarizes the key evaluation questions for assessing the 

implementation of the National CLAS Standards within an organization and the process and 

impact measures that HCOs may wish to use to help answer these questions. Chapter Eight 

concludes with a summary of the evaluation framework and a brief overview of the companion 

toolkit to this report, which is designed to support health organizations in their efforts to 

implement the National CLAS Standards and improve their capacity to evaluate their approach. 

Appendix A contains the list of the TAG members. Appendixes B through F contain detailed 

tables listing the cross-cutting process and impact measures and setting-specific measures for 

ambulatory care, hospitals, behavioral health, and public health. 

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Chapter Two. Conceptual Framework
 

As noted, in 2013, HHS OMH released the revised National CLAS Standards, establishing a 

new benchmark for culturally and linguistically appropriate services to improve the health of all 

individuals. These revised National CLAS Standards provided a vision of what culturally and 

linguistically competent care looks like when implemented to its fullest and offered practical 

suggestions for how this vision could be implemented within health care settings. HHS OMH 

asked RAND to help develop a long-term evaluation framework for the National CLAS 

Standards in a range of health settings, which include health care settings as well as broader 

settings responsible for the promotion of health and well-being. The conceptual framework 

shown in Figure 2.1 is a key element of this effort. 

This conceptual framework is overarching in that it is relevant across a range of health 

settings, including ambulatory care centers (such as Federally Qualified Health Centers 

[FQHCs]), hospitals, behavioral health settings, and public health agencies. This conceptual 

framework was adapted from an existing model developed by Greenhalgh and colleagues (2004) 

that is focused on the diffusion of innovations in health service organizations. The framework 

conceptualizes the National CLAS Standards as an innovation to be adopted within the health 

setting. The ultimate goal to be achieved through the adoption of the National CLAS Standards is 

defined in the Principal Standard (Standard 1): “to provide effective, equitable, understandable, 

and respectful quality care and services that are responsive to diverse cultural beliefs and 

practices, preferred languages, health literacy, and other communication needs” (HHS OMH, 

2013). 

Our conceptual framework describes the inputs, activities, outputs, and outcomes occurring 

within the health organization and illustrates how the National CLAS Standards are implemented 

and adopted. The framework also highlights the important roles of community and stakeholder 

engagement and partnerships for the diffusion and sustainability of the National CLAS Standards 

within an organization and explicitly acknowledges the broader environmental and policy 

context that can affect progress. 

Whether and how readily an organization is willing and able to adopt the National CLAS 

Standards depends on a number of factors relevant to the National CLAS Standards themselves. 

This includes the organization’s understanding of them, the availability of guidelines and 

examples of best practices, and the perceived relative advantage to the organization of 

implementing the National CLAS Standards. Organizations will need to assess how compatible 

the National CLAS Standards are with current organizational goals, practices, and other 

regulations or guidelines they must follow and how complex or easy the National CLAS 

Standards are to understand and adopt into practice. 

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Figure 2.1. Conceptual Framework for the Diffusion of the National CLAS Standards 

Diffusion Within the Health Organization 

The section of the framework that is shaded in blue on the right-hand side describes the 

diffusion of the National CLAS Standards within a given health organization. It includes 

organization-specific antecedents and inputs; readiness for adopting the National CLAS 

Standards; the development of implementation strategies and communication about proposed 

strategies; activities related to the adoption, assimilation, and diffusion of the National CLAS 

Standards; and outputs and outcomes to both internal and external audiences. 

Antecedents and Inputs 

Antecedents and inputs relevant to the implementation of the National CLAS Standards 

include the organization’s strategic goals, policies, dedicated staff and resources, physical 

environment, and external resources. Also relevant is the organization’s capacity to absorb new 

knowledge and receptivity for change, which may be driven, for example, by a gap analysis or 

needs assessment. Examples of antecedents and inputs are described below. 

•	 Strategic goals reflect the organizational priorities for resource use and deployment. It is 

critical that organizations formulate goals related to the National CLAS Standards as part 

of their strategic planning. 

•	 Policies “express an organization’s intentions and provide a blueprint for action” 

(Dreachslin and Hobby, 2008). Therefore, formal policies that address cultural 

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competency issues—such as recruitment and retention of a diverse workforce, language 

services, and training and development—will strengthen the implementation of activities 

related to the National CLAS Standards (Lewin Group, 2002; Wilson-Stronks and 

Galvez, 2007). These internal policies should at least conform with external regulatory 

and statutory policies. 

•	 Dedicated staff and resources confirm an organization’s commitment to cultural 

competency by dedicating resources and designating staff for cultural competency 

activities. Evidence of dedicated resources can be found in budgeted resources for 

cultural competency activities (Lewin Group, 2002; Wilson-Stronks and Galvez, 2007). 

Dedicated staff can include an executive-level staff member and a department or office 

that focuses on multicultural and/or linguistic issues. Dedicated staff can be instrumental 

in coordinating organization-wide initiatives and monitoring progress toward cultural 

competency goals (Brach, Paez, and Fraser, 2006; Wilson-Stronks and Galvez, 2007). 

•	 The physical environment includes culturally sensitive design and architecture and 

physical environments in which the décor, artwork, posters, and literature reflect the 

diversity of the service area (Lewin Group, 2002). It also includes appropriate signage in 

the major languages spoken in the service area (HHS OMH, 2001). 

•	 External resources, such as partnerships with the community or other stakeholders, can 

be valuable inputs to the process through shared meaning and mission, knowledge, and 

other resources (e.g., personnel, materials). 

•	 An organization’s capacity for new knowledge—building on an organization’s 

preexisting knowledge and skills base relative to the National CLAS Standards—is the 

ability to find, interpret, and use new knowledge and share that knowledge through 

internal and external networks. This is related to the completion of a gap analysis or 

needs assessment that may help to inform activities that may be undertaken to meet the 

National CLAS Standards. 

•	 An organization’s receptivity for change includes the type of leadership and vision 

within the organization, the risk-taking climate, and whether the organization has clear 

goals and priorities that align with the National CLAS Standards. 

Readiness for the National CLAS Standards 

Regardless of whether antecedents and inputs relevant to successful implementation of the 

National CLAS Standards are present, they likely will not be implemented if the health setting or 

organization is not ready to change. Readiness for change may be affected by a number of 

factors, including the following: 

•	 A recognition of the need for change: The organization recognizes a clear need for 

change relative to its ability to provide effective, equitable, understandable, and 

respectful quality care and services that are responsive to a diverse population. 

•	 Business case and quality improvement case: One of the major organizational barriers 

for the National CLAS Standards is the perceived impact it may have on costs. It is 

therefore important that both the business case and the quality improvement case for the 

National CLAS Standards have been made (e.g., leadership and staff see how 

implementation can improve outcomes and the financial bottom line). 

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• Leadership and executive buy-in: Activities related to the National CLAS Standards 

are most effective when the organization’s governing board and top management 

embrace cultural competence and communicate this support throughout the organization 

(Brach, Paez, and Fraser, 2006; Dansky et al., 2003). This includes incorporating criteria 

related to the National CLAS Standards into the performance evaluation and reward 

systems. 

•	 Champions or change agents, either individually or as a group, who can spearhead 

forward momentum and help address readiness for adopting the National CLAS 

Standards throughout the broader organization. 

Development of Implementation Strategies and Communication 

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 

and develop thoughtful implementation strategies for the proposed changes. Organizations may 

adopt the National CLAS Standards all at once or in a staged approach, depending on the 

antecedents and inputs, readiness, and the environmental and policy context. Many of the 

National CLAS Standards themselves can be viewed as thoughtful implementation strategies for 

the provision of effective, equitable, understandable, and respectful quality care and services. A 

review of 73 implementation strategies identified in the Expert Recommendations for 

Implementing Change (ERIC) study (Powell, Waltz, et al., 2015), for example, identified nine 

categories of strategies: (1) engage consumers, (2) use evaluative and iterative strategies, (3) 

change infrastructure, (4) adapt and tailor the context, (5) develop stakeholder interrelationship, 

(6) utilize financial strategies, (7) support clinicians, (8) provide interactive assistance, and (9) 

train and educate stakeholders. Many of these strategies are reflected or implicit in the National 

CLAS Standards, with examples provided below. 

•	 Appoint a committee of stakeholders to guide activities related to the National 

CLAS Standards. This committee should include organization staff, members of the 

community, and other stakeholders who can bring unique perspectives to the planning 

process. 

•	 Design and plan changes or activities to address identified needs. Such changes may 

relate to one or more of the National CLAS Standards: 

−	 Governance, leadership, and workforce (National CLAS Standards 2–4). One 

example of an activity meeting these National CLAS Standards is the development of 

cross-cultural communication skills among all staff, including skills to obtain 

culturally relevant data, such as those used in conducting cultural assessments and 

culturally based physical assessments (Campinha-Bacote, 2002; Kim-Godwin, 

Clarke, and Barton, 2001; DeRosa and Kochurka, 2006; Hobgood et al., 2006). This 

also includes skills needed in “identifying and negotiating different styles of 

communication, decision-making preferences, roles of family, sexual and gender 

issues, and issues of mistrust, prejudice, and racism” (Betancourt et al., 2003). 

− Communication and language assistance (National CLAS Standards 5–8). The 

National CLAS Standards related to patient communication can be pivotal in 

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improving the patient experience. This includes, for example, providing interpreter 

and translation services. High-quality interpreter services are needed at all points of 

patient contact to improve provider and staff communication with patients with 

limited English proficiency (LEP). Accurate communication increases the likelihood 

of receiving appropriate care (HHS OMH, 2001; Anderson et al., 2003; WilsonStronks and Galvez, 2007). 

−	 Engagement, continuous improvement, and accountability (National CLAS Standards 

9–15). Activities within this set of National CLAS Standards may foster refinement 

between adoption, implementation, and outcomes. One example of an activity 

meeting these specific National CLAS Standards may be implementing mechanisms 

for collecting data on cultural subgroups, such as race/ethnicity, language 

preferences, education, and income, and integrating these data into the information 

systems (HHS OMH, 2001; Lewin Group, 2002). These data are important for 

strategic and service planning and can be used to monitor health care disparities and 

for quality improvement (QI) (Betancourt, Green, and Carrillo, 2002). 

•	 Develop implementation strategies. This stage should include the development of 

implementation strategies for the proposed changes. Implementation strategies are 

defined as “methods or techniques used to enhance the adoption, implementation, and 

sustainability of a clinical program or practice” (Powell et al., 2015). 

•	 Communicate about the National CLAS Standards’ implementation and activities. 

Communication should occur internally to promote acceptance and understanding of 

upcoming changes. It is also important to communicate about the implementation, 

activities, and expectations of the National CLAS Standards to contracted or network 

providers and partners because they will influence the organization’s overall CLAS 

performance with respect to the National CLAS Standards. External communication may 

also improve community relations if organizations can raise public awareness of the 

activities and their progress in meeting goals related to the National CLAS Standards 

(HHS OMH, 2001; Lewin Group, 2002). External communication can include a 

statistical annual report on patient demographics, interpreter use and availability, 

translated materials, staff training in cultural competency, and survey results of patient 

experiences with care. This can serve as a marketing tool while enhancing the 

organization’s image among diverse communities. 

Adoption/Implementation 

Once activities to address gaps in the National CLAS Standards have been identified and 

designed, they must be adopted, implemented, and devolved to frontline teams for execution. 

Successful implementation may require 

•	 a hands-on approach by leadership and managers to ensure fidelity to the implementation 

plan and feedback on progress 

•	 human resources involvement, especially related to training, professional development, 

and workforce evaluations 

•	 collection, monitoring, and use of data on race, ethnicity, sex, sexual orientation, 

disability status, and language
 

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•	 tracking of process and outcome data to assess progress in achieving goals—along with 

data on the population served, these data should inform continuous quality improvement 

(CQI) efforts 

•	 dedicated resources and time to allow for full implementation of planned changes. 

Outputs and Outcomes 

The activities and changes implemented within the organization are expected to result in 

immediate outputs that move the organization closer to providing culturally and linguistically 

appropriate care and services. Such outputs may include 

•	 incorporating diverse viewpoints from inside and outside the 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 the organization’s 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 providers and staff at all levels of the organization 

•	 improving the physical layout, signage, ease of access, and navigation 

•	 improving the collection of, access to, and dissemination of accurate population data, 

particularly for ethnic and minority populations 

•	 ensuring that resources and accountability to support and sustain National CLAS
 

Standards–related initiatives and efforts are available
 

•	 ensuring that staff understand the benefit of implementing the National CLAS Standards 

for both the organization and the individuals they serve. 

Collectively and over time, such outputs may contribute to changes in outcomes for both the 

organization as a whole and for the individuals engaging in services. It is expected that some 

outcomes will take longer to realize. Examples of outcomes are provided below. 

• Outcomes for the organization: 

−	 the provision of quality care and services that are responsive to diverse cultural health 

beliefs and practices, preferred languages, health literacy, and other communication 

needs 

− data that are used to monitor and improve service delivery with respect to the 

National CLAS Standards 

− improved two-way communication and feedback mechanisms between individuals 

and health care settings 

− organizational culture shifts to provide ongoing and visible support for the National 

CLAS Standards 

− continued improvement in the provision of high-quality services related to the 

National CLAS Standards 

− increased trust and engagement between the community and the health care setting. 

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• Outcomes for the individuals seeking care: 

• access to high-quality language services 

• increased ability to access and navigate care 

• increased ability to understand care and make informed care decisions 

• greater adherence to care plans, completing treatment, and appropriate follow-up 

• being empowered to become active participants in their health 

• improved satisfaction 

• better health outcomes 

• increased trust between individuals and providers. 

Quality Improvement 

Organizations should integrate the National CLAS Standards into their QI activities, as 

depicted in the model. QI can be viewed as an organization-wide approach to planning and 

implementation of continuous improvement in performance. As such, QI “emphasizes 

continuous examination and improvement of work processes by teams of organizational 

members trained in basic statistical techniques and problem-solving tools and empowered to 

make decisions based on the analysis of data” (Weiner et al., 2006). For example, HCOs can use 

QI activities to address health disparities in access, outcomes, or patient experiences with care. 

The outputs and outcomes generated as a result of the implementation of the National CLAS 

Standards also feed back to the broader community and other stakeholders. For example, if 

anticipated impacts of the National CLAS Standards are realized, the needs of the community 

over time may change, relationships between the health system and community may strengthen, 

and new opportunities for partnership may arise. Furthermore, as the number of organizations 

meeting the National CLAS Standards increases within a given community or system, the 

collective impact may affect outcomes at the community, system, and/or policy levels, although 

this will take a longer period of time. At the system level, this may include improved quality of 

care, increased capacity of the health system to address the needs of diverse populations, 

increased equity, reduced disparities, and lower health care costs. It may also result in improved 

population health overall. 

Linkages with the Community and Other Stakeholders 

Successful implementation of the National CLAS Standards requires clear and meaningful 

linkages between the health setting, the community, and relevant stakeholder groups to 

understand and address the cultural and linguistic needs of the communities served (WeechMaldonado and Merrill, 2000; Wilson-Stronks and Galvez, 2007). Such stakeholders may 

include tribal or community-based organizations, such as human, social service, and religious 

organizations, as well as liaisons like community health workers (Lewin Group, 2002; Brach and 

Fraser, 2000). Linkages between the organization and community should occur throughout the 

process. For example, in the design stage, such linkages may promote a shared mission, effective 

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knowledge transfer, and lessons learned from past efforts. Community members and 

representatives from various stakeholder groups should also participate in any gap analysis or 

needs assessment (see the “Antecedents and Inputs” section earlier in this chapter) and 

workgroups to develop solutions to address gaps (see the “Adoption/Implementation” section 

earlier in this chapter). Linkages with the community and with other stakeholders are also critical 

for implementing planned changes or activities, particularly with respect to information- and 

data-sharing, implementation support, and resource-sharing (e.g., joint training). Finally, 

linkages with the community and other stakeholders are important for communicating with key 

audiences about the National CLAS Standards and about improvements made within the 

organization. It is important to note that both formal and informal linkages also occur between 

the community, other stakeholders, and HHS OMH. 

Linkages with HHS OMH also exist within the health setting, through the development of the 

National CLAS Standards, through the sharing of best practices and lessons learned, and through 

the development of the evidence base to assess the effectiveness of the National CLAS 

Standards. This linkage, however, is not as strong or as often utilized as linkages with the 

community. 

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, including 

•	 the federal, state, and local regulatory environment (e.g., ACA, Civil Rights Act, Public 

Health Service Act) 

•	 accreditation mandates 

•	 policies 

•	 incentives and payment models (e.g., for culturally competent care) 

•	 standards of practice 

•	 reporting requirements (e.g., CAHPS). 

In many cases, these factors influence how care is delivered and monitored and may impact 

whether and how organizations choose to adopt the National CLAS Standards. To the extent that 

the National CLAS Standards align with many of these existing regulatory and reporting 

requirements, organizations may be more likely to adopt the National CLAS Standards. 

However, if organizations see the National CLAS Standards as duplicative or as additional work 

for their already overtaxed organization, they may be less likely to adopt the National CLAS 

Standards. In the framework in Figure 2.1, the environmental and policy context surrounds the 

health organization and the entire process of adopting the National CLAS Standards, but the 

dashed lines around the organization are meant to indicate that the environmental and policy 

context is both a foundation for these activities and an important driver for them within an 

organization. 

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Conclusion 

This framework conceptualizes the National CLAS Standards as an innovation to be adopted 

within health care settings. It was designed to be relevant across a range of health and health care 

settings, including ambulatory care centers (such as FQHCs), hospitals, behavioral health 

settings, and public health agencies. Building from the conceptual framework, the next step was 

to formalize specific logic models for the four different types of health and health care 

organizations addressed in this effort. By clearly defining the inputs, activities, outputs, and 

short- and long-term outcomes resulting from the awareness, adoption, and implementation of 

the National CLAS Standards within the HCO, the logic models provide a solid foundation for 

the design of an evaluation and help to ensure that the measures used capture relevant processes 

and potential impacts. The setting-specific logic models are described in the following four 

chapters on ambulatory care (Chapter Three), hospitals (Chapter Four), behavioral health 

(Chapter Five), and public health (Chapter Six). 

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Chapter Three. Ambulatory Care Logic Model
 

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 more than 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, as well as 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, our focus is 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, as in the case of the other types of health care organizations (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 the U.S. Department of Health and Human Services (HHS) Office of 

Minority Health (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). 

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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 

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 at 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 patients who do not speak English, 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. 

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Logic Model for Implementing the National CLAS Standards Within the 

Ambulatory Care Setting 

Figure 3.1 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 National CLAS 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 the 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 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). 

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 19
 

Figure 3.1. Logic Model for Implementation of 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 National CLAS 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 Affordable 

Care Act (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 National CLAS Standards include the following: 

•	 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) and the Agency for Healthcare Research and Quality’s 

(AHRQ’s) Ambulatory Consumer Assessment of Healthcare Providers and Systems 

(Bureau of Primary Health Care, 2015). 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. Because outcomes tend to be worse in 

minority and/or lower–socioeconomic-status populations where cultural 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 National CLAS Standards will likely take time in many 

ambulatory settings, 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, though not all, ACSs have 

undergone a transformation in recent years with respect to improvements in their 

electronic medical records 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 show only 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). One of the Act’s stated goals is to address health disparities. The Electronic 

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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). 

•	 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 limited 

English proficiency (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 on 

Accreditation of Healthcare Organizations (JCAHO)—have also established accreditation 

standards that target the improvement of communication, cultural competency, and patientcentered 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 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 National 

CLAS 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— 

21
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 National CLAS 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 continuous quality improvement 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 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 National CLAS 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 National CLAS Standards into the 

organization’s approach is especially important when the ACS seeks to implement the National 

CLAS Standards across multiple providers and office locations. 

Changes to an ACS’s organizational structure, staffing, and resources require that the ACS 

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 

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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 National CLAS 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. 

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. 

23
 
 

 

 

 

 

 

 

 

 

The above serve as examples of potential outputs. The specific outputs expected will be 

determined by which National CLAS Standards have been adopted, which organizational 

changes have been made, and which activities have been implemented as a result. 

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. 

•	 Outcomes for the organization 

−	 Short term (1–2 years) 

▪ the provision of 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 

▪ use of data on race, ethnicity, sex, sexual orientation, disability status, and 

language 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 

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. 

• Outcomes for the individuals seeking care 

−	 Short term (1–2 years) 

▪ access to high-quality language services 

▪ increased ability to access and navigate ambulatory care services to receive 

primary, preventive, and acute care services 

▪ increased ability to understand treatment options and make informed care 

decisions 

▪ ability to understand and navigate the referral process to see specialists 

▪ greater adherence to medication and treatment protocols and follow-up visits 

− Longer term (3 or more years) 

▪ empowerment to become active participants in their health 

▪ improved satisfaction among those seeking ambulatory care services 

24
 
 

 

 

 

 

 

▪ 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 

▪ reduction in disparities 

▪ improved health and well-being. 

Quality Improvement 

The logic model depicts adoption and implementation of the National CLAS Standards as a 

continual process, requiring a QI loop in which 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. 

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Chapter Four. Hospital Logic Model
 

There are more than 5,500 registered hospitals in the United States, the majority of which are 

community hospitals. These consist of not-for-profit, 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 (Centers for 

Disease Control and Prevention [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 limited English proficiency (LEP) or no 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 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 is somewhat limited. While 77 percent of responding hospitals 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 the U.S. reimbursement system and paying for 

26
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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) 

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, decreased use of preventive services, lower rates of 

adherence to medications, and lower 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 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 WeechMaldonado 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 accountable care organizations (ACOs). 

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Logic Model for Implementation of the National CLAS Standards Within the 

Hospital Setting 

Figure 4.1 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 National CLAS 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 who 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, 2017; 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 utilization. In addition, these 

linkages are critical given the emergence of ACOs, where hospitals are assuming risk for the 

episode 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. Because 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. CLAS activities can improve quality and 

outcomes and lower costs of care that patient insurers and/or employers pay. As such, both 

28
 
 

 

 

insurers (e.g., health plans) and employers can be partners in hospital efforts to increase cultural 

competency and other CLAS activities within the hospital or in the surrounding community. 

Such partners should be involved at all stages of National CLAS Standards adoption (e.g., 

assessment, design, implementation, evaluation). 

29
 
 30
 

Figure 4.1. 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., 

the Affordable Care Act [ACA]), state, tribal, and local regulatory environments; 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 National CLAS 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 (U.S. Department of Health and Human Services 

[HHS] Office of Minority Health [OMH], 2016b). Accrediting bodies, such as the JCAHO and 

the National Committee for Quality Assurance, 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; WilsonStronks 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. 

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, not for profit) 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. 

31
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

External factors, such as competition, can provide an impetus for cultural competency activities 

as hospitals strive to increase or maintain their market share in areas with 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 of 

the National CLAS Standards. Of note, all not-for-profit hospitals are required to complete a 

community health needs assessment (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 that 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 for National CLAS 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. 

32
 
 

 

 

 

 

 

 

 

 

 

 

 

 

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 

•	 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 quality improvement (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 

both for individuals using inpatient services and for the hospital overall. Examples of potential 

outcomes within the hospital setting are listed below. 

• Outcomes for the organization: 

−	 Short term (1–2 years) 

▪ the provision of 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 use of data on race, ethnicity, sex, sexual orientation, disability status, and 

language to monitor and improve service delivery within the hospital 

▪ 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 

33
 
 

 

 

 

 

 

 

 

 

 

 

−	 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. 

•	 Outcomes for the individuals seeking care: 

−	 Short term (1–2 years) 

▪ access to high-quality language services 

▪ increased ability to access and navigate hospital services 

▪ increased ability to understand treatment options and make informed care 

decisions 

▪ ability to understand and follow pre- and post-operative or test instructions and 

discharge plans 

▪ connection 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. 

Quality Improvement 

The logic model also depicts the adoption and implementation of the National CLAS 

Standards as a continual process, requiring a QI loop in which 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. 

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Chapter Five. Behavioral Health Logic Model
 

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 (U.S. Department of Health and Human Services [HHS], 2001).3 

3 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, in the community, and in 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, and 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 ambulatory care settings (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. 

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 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). 

35
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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; Agency for Healthcare Research and Quality [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 NIMH to include mental 

health disparities as a cross-cutting research theme in its 2015 Strategic Plan for Research 

(NIMH, 2015). 

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 helpseeking 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). 

Logic Model for Implementation of the National CLAS Standards Within the 

Behavioral Health Setting 

Figure 5.1 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 5.1, 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 

36
 
 

 

 

 

 

 

 

 

 

 

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 services 

(e.g., ACSs and 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. These 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 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, the 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). 

37
 
 38
 

Figure 5.1. 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 environments; 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 National 

CLAS 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 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act 

of 2008 (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.4 

4 The Centers for Medicare & Medicaid Services’ (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. 

Of particular importance is the Affordable Care Act (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 non-grandfathered individual and small-group plans 

(including those in the state and federal marketplaces) 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 would 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. 

39
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 provide the rationale and the background information 

that support 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 

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.

5 

5 SAMHSA’s framework draws on the 2005 guidance of the National Center for Cultural Competence at 

Georgetown University’s Center for Child and Human Development, 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 National 

CLAS Standards outline specific action steps that health organizations or health care 

organizations, 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, not for 

profit) and on whether the behavioral health organization is part of a system or network (e.g., 

behavioral health managed care network). Inputs and antecedents such as the behavioral health 

organization’s strategic goals, policies, staff, resources, and physical environment 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 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 

40
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 and an assessment of 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 those who do not speak 

English, 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 they 

help to shape the activities that the organization chooses to implement to address gaps in 

culturally and linguistically appropriate care. 

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 that 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 in meeting the National 

CLAS Standards; identification of priorities; and the design, development, and implementation 

of activities to address those gaps are expected to be done with input from, and 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 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
 

41
 
 

 

 

 

 

 

 

 

 

 

 

•	 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. 

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. 

•	 Outcomes for the organization: 

− Short term (1–2 years) 

▪ the provision of effective, equitable, understandable and respectful 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 

▪ increased buy-in from staff on organizational changes made to implement the 

National CLAS Standards 

− Longer term (3 or more years) 

▪ organizational culture shifts that 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 National CLAS Standards 

▪ improved behavioral health and health outcomes 

▪ increased equity in access to high-quality behavioral health services and a 

reduction in health disparities 

42
 
 

 

 

 

 

 

 

 

 

 

 

 

 

▪ increased trust and engagement between the community and behavioral health 

care providers and organizations. 

•	 Outcomes for the individuals seeking care: 

−	 Short term (1–2 years) 

▪ access to high-quality language services for individuals seeking specialty 

behavioral health care 

▪ ability to access and navigate specialty behavioral health care services 

▪ ability to understand mental health and other treatment options and make 

informed behavioral health care decisions 

▪ greater adherence to medication and treatment protocols
 

− Longer term (3 or more years)

▪ empowerment to become active participants in 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 followup 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 quality improvement (QI) loop. For example, 

behavioral health organizations can assess their performance by applying for Behavioral Health 

Accreditation (the Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 

2007), psychologists can assess how well they are following the American Psychological 

Association Guidelines, and consumers can provide feedback on their experiences with 

behavioral health treatment using the Experience of Care and Health Outcomes (ECHO) survey.

6 

6 Similar to the Consumer Assessment of Healthcare Providers and Systems (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. 

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Chapter Six. Public Health Logic Model
 

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 (Centers for Disease Control and 

Prevention [CDC], 2017). 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, 

2017): 

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 6.1). 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. 

Table 6.1. Linking the National CLAS Standards to Core Public Health Functions 

Core Public Health 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 that evaluations capture cultural 

and linguistic differences 

Despite the natural alignment between the National CLAS Standards, the core functions of 

public health, and the populations that LHDs commonly serve, the acceptance of the National 

CLAS 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 6.2). For example, LHDs often already include professionals who reflect the 

44
 
 

 

 

 

 

 

 

 

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 public 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. 

Table 6.2. Diverse LHD Organizational Arrangements 

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 health 

department, tribal health department, 

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 

These vary considerably. 

NOTE: Adapted from data provided in Brownson et al., 2012. 

Logic Model for Implementation of the National CLAS Standards Within the 

Public Health Setting 

Figure 6.1 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. 

45
 
46
 

Figure 6.1. Logic Model for Implementation of the National CLAS Standards Within the Public Health Department Setting 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 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, and 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 National CLAS 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/infectious disease and chronic disease 

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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 they 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 National CLAS Standards in their communities. 

Environmental and Policy Context 

A number of factors external to the organization itself affect the implementation of the 

National CLAS Standards within an organization. These external factors include, for example, 

the federal (e.g., Affordable Care Act), state, tribal, and local regulatory environments; 

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 choose to 

adopt the National CLAS Standards. 

Within the public health setting, there are various requirements that regulate workforce 

training, services and programs delivered, and disease monitoring, including those from the 

Association of Public Health Laboratories and the CDC. To the extent that the National CLAS 

Standards align with or leverage these requirements, it will be easier for LHDs to implement 

them. In addition, there is a new accreditation process for public health departments. It is not 

required, and only a small portion of LHDs have completed the process (Public Health 

Accreditation Board, undated). However, several standards in the accreditation process are 

relevant to the National CLAS Standards. These may serve as a platform for increasing the 

implementation of the National CLAS Standards among LHDs as they move toward 

accreditation. The accreditation standards that most align with the National CLAS Standards 

include 

•	 Standard 7.1: Assess Health Care Service Capacity and Access to Health Care Services 

•	 Standard 7.2: Identify and Implement Strategies to Improve Access to Health Care 

Services 

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•	 Standard 8.1: Encourage the Development of a Sufficient Number of Qualified Public 

Health Workers 

•	 Standard 8.2: Ensure a Competent Workforce Through Assessment of Staff 

Competencies, the Provision of Individual Training and Professional Development, and 

the Provision of a Supportive Work Environment. 

These examples of external influences and contexts may affect whether and how an LHD 

will adopt the National CLAS Standards and how easy or difficult such implementation may be 

for the organization. 

Public Health Context, Resources, Community, and Catchment Area 

Inputs and antecedents relevant to the implementation of the National CLAS Standards 

include the organization’s strategic goals, policies, staff, resources, and physical environment. 

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 needs assessment. 

Despite similar core functions, LHDs vary significantly with respect to reach, size, 

governance, jurisdiction, and funding sources—all of which are relevant inputs to adopting and 

implementing the National CLAS Standards (see Table 6.2). 

One challenge is that LHDs are often constrained by the diversity of their arrangements 

because funding priorities are often set by external organizations, typically at the federal and 

state levels (NACCHO, 2006); by political mandates; and by natural population shifts. This 

means that LHDs often lack the internal capacity to allocate resources for implementing new 

initiatives. This problem may be exacerbated in smaller LHDs, where there are fewer overall 

resources. A recent review of the literature suggests that some characteristics, such as size of 

population served, budget, and governance, predict LHD performance (Hyde and Shortell, 2012). 

Adopting the National CLAS Standards within these different contexts may be complicated 

because it is not clear which mechanisms are related most closely to LHD decisionmaking and 

priority-setting. More importantly, the multiple demands on LHD priorities mean that it is likely 

that prioritization of the National CLAS Standards would have to come from multiple 

policymaking and funding authorities. 

A final input worth noting is that a strength of many LHDs is population-level data collection 

and analysis. Given that a core function of public health is monitoring and evaluating the 

effectiveness, accessibility, and quality of personal and population-based health services, many 

LHDs have conducted community health assessments (CHAs). These assessments provide a 

more in-depth look into the health needs of the community and may identify key gaps in 

culturally or linguistically appropriate activities, structures, or policies. They may also include an 

analysis of implementation factors that could aid or hinder the adoption of the National CLAS 

Standards. LHDs conduct CHAs using such tools as Mobilizing for Action through Partnerships 

and Planning (NACCHO, 2016). CHAs and other existing data-collection efforts may be helpful 

inputs as LHDs look to adopt and implement the National CLAS Standards. 

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National CLAS Standards 

In this logic model, the National CLAS Standards are placed between the antecedents and 

inputs and the activities that 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 that the organization chooses to implement to address gaps in 

culturally and linguistically appropriate care within the public health 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 alleviate these 

gaps. Organizations may adopt the National CLAS Standards altogether or in a staged approach, 

depending on the antecedents and inputs, the organization’s readiness for change, and the 

environmental and policy context. Given the wide range of potential approaches and activities 

that an LHD 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. One example of a potential policy is the provision of transportation for individuals who 

do not speak English well enough to safely and successfully navigate the public transit system. 

Engaging diverse viewpoints from inside and outside the organization into planning is 

particularly important. Building this orientation into the organization’s approach is especially 

important when an LHD seeks to implement the National CLAS Standards among its community 

partners. 

Changes to LHD organizational structure, staffing, and resources require that the LHD and 

its partners have identified the necessary skill set for their staff to address cultural and linguistic 

needs, have the capacity to train staff when necessary, and ensure retention and minimal turnover 

to help build trust and rapport with the community. In addition, the organization should be 

focused on diversifying its frontline staff and ensuring an ethnically diverse staff at all levels, 

including boards and senior administration, even in circumstances when its internal needs 

assessments lead it to implement a subset of the National CLAS Standards or within a limited set 

of LHD activities. This is particularly important given that LHD policies are set by a number of 

different bodies that sometimes include leadership outside the organization’s own staff. Changes 

to organizational structure include making improvements in the ease of access to its physical 

space and to the information it provides to consumers through signage. In addition, the LHD 

would have dedicated resources to support and sustain the implementation of the National CLAS 

Standards, including language services and a process for holding itself and its partners 

accountable for these improvements. 

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Changes to processes and practices encompass all the unique functions of public health, 

including improved collection and access to population data, communicating complex health 

information that is actionable to everyone in the community, and providing access to this 

information in multiple languages using high-quality translations. 

It is expected that the identification of gaps and priorities and the design and development of 

activities to address those gaps will be done in close collaboration with the community and other 

stakeholders that stand to benefit from such changes. Because of the varied and complex ways 

that public health can be organized, the results of these analyses will be very different. Many 

LHDs are uniquely positioned to draw out these lessons from stakeholders because of their longstanding partnerships, but not all LHDs are. Prioritizing the National CLAS Standards with 

respect to organizational policy, practice, staffing, and resources is critical to ensuring that every 

LHD, no matter the context, takes appropriate steps to ensure that its services are accessible by 

all members of the community. 

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 LHD 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 public health practitioners and staff at all levels of the 

LHD 

•	 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. 

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 LHDs may contribute to changes in outcomes, both 

for individuals using public health services—regardless of whether they are provided directly by 

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the LHD or by a partner—and for the LHD overall. Examples of potential outcomes within the 

public health setting are listed below. 

•	 Outcomes for the organization: 

−	 Short term (1–2 years) 

▪ the provision of 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 use of data on race, ethnicity, sex, sexual orientation, disability status, and 

language to monitor and improve public health service delivery 

▪ racial/ethnic and linguistic concordance between public health practitioners and 

individuals seeking services 

▪ higher-quality messages and materials to convey public health and safety 

information and warnings 

− Longer term (3 or more years) 

▪ organizational culture shifts that provide ongoing and visible support for the 

National CLAS Standards within LHDs and within community partners providing 

health-related services on behalf of the LHD 

▪ continued improvement in the provision of high-quality public health services 

related to the National CLAS Standards 

▪ increased equity in access to high-quality public health services and a reduction in 

health disparities 

▪ increased trust and engagement between the community, the LHD, and its 

partners 

▪ improved capacity to achieve the public health mission and its core functions. 

•	 Outcomes for the individuals seeking care: 

− Short term (1–2 years) 

▪ increased ability to access and navigate public health services 

▪ increased ability to understand and adhere to public health guidance, warnings, 

directives, and emergency communications 

▪ better and earlier detection of health concerns through appropriate screenings 

▪ greater participation in vaccinations and other preventive health programs 

− Longer term (3 or more years) 

▪ improved population health and safety 

▪ improved satisfaction among individuals seeking public health services 

▪ increased trust between the community and public health organizations 

▪ reduced disparities. 

Quality Improvement 

The logic model depicts the adoption and implementation of the National CLAS Standards as 

a continual process, requiring a quality improvement (QI) loop. Many LHDs have assessed their 

own performance with such tools as the CDC’s National Public Health Performance Standards 

Program and NACCHO’s Local Health Department Self-Assessment Tool; these tools may be 

52
 
 

 

helpful in assessing the success and effectiveness of the National CLAS Standards 

implementation. Furthermore, since 2003, there has been guidance for LHDs on developing 

organizational self-assessments, which measure culturally and linguistically appropriate services. 

As a result, LHDs are very familiar with self-monitoring for QI (COSMOS Corporation, 2003). 

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Chapter Seven. Evaluation Questions and Process Outcomes 

and Impact Measures 

In earlier chapters, we presented both a conceptual framework and setting-specific logic 

models to help organizations begin to assess the extent to which the National CLAS Standards— 

and the related changes that HCOs put in place to address these them—result in an improved 

ability “to 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” (Principal Standard, HHS OMH, 2013). In this 

chapter, we provide additional detail on key evaluation questions and measures that can be used 

as part of process and outcomes evaluations. 

A process evaluation determines whether program or intervention activities (in this case, 

activities related to the National CLAS Standards) have been implemented as intended and have 

resulted in certain outputs. This type of evaluation informs one about the extent to which the 

proposed change (e.g., policy, training, intervention) is being implemented as designed; whether 

the change is working and reaching the intended audience; and what adjustments, if any, are 

needed. A process evaluation can also inform the results of outcomes or impact evaluations, 

helping to assess why the changes were or were not as successful as the organization had hoped. 

An outcomes evaluation measures program or intervention effects by assessing the progress 

in the desired outcomes or outcome objectives (SAMHSA, 2016). An impact evaluation assesses 

overall program effectiveness in achieving its ultimate goals. Outcome measures typically reflect 

short- and intermediate-term results, whereas impact measures are the direct or indirect longterm effects or consequences of the outcomes (in terms of overall effectiveness or efficiency), 

resulting from achieving program or project objectives and goals (HHS OMH, 2010). We use the 

term impact/outcomes evaluation to include both short- and intermediate-term outcomes, as well 

as the longer-term effects of implementing the National CLAS Standards. Thus, the questions we 

developed below address both the process of implementing the National CLAS Standards and 

the results (impact and outcomes) of these changes or activities. In this chapter, we not only 

provide an overview of the evaluation questions developed to support the implementation of the 

National CLAS Standards within an HCO; we also include a number of key measures that 

organizations may wish to use to help answer these questions. These measures were selected 

both for their strong psychometric properties (e.g., reliability, validity) and because they are 

readily available or already collected as part of the organization’s ongoing QI or accreditation 

processes. 

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Evaluation Questions 

To develop the list of process and impact or outcomes evaluation questions, we began with a 

literature review of assessments, tools, and resources for measuring cultural competence and 

access to linguistic services, both in general and specific to the four settings that are the focus of 

this project. Examples of key resources reviewed included 

•	 the National Quality Forum’s (NQF’s) A Comprehensive Framework and Preferred 

Practices for Measuring and Reporting Cultural Competency (NQF, 2009) 

•	 NCQA’s Multicultural Health Care: A Quality Improvement Guide (Briefer French et 

al., 2008) 

•	 the Lewin Group’s Indicators of Cultural Competence in Health Care Delivery 

Organizations: An Organizational Cultural Competence Assessment Profile (Lewin 

Group, 2002) 

•	 Weech-Maldonado and colleagues’ “The Consumer Assessment of Healthcare 

Providers and Systems (CAHPS) Cultural Competence (CC) Item Set” (WeechMaldonado et al., 2012b) 

•	 Diamond and colleagues’ “Do Hospitals Measure up to the National Culturally and 

Linguistically Appropriate Services Standards?” (Diamond, Wilson-Stronks, and 

Jacobs, 2010) 

•	 Weech-Maldonado and colleagues’ “Cultural Competency Assessment Tool for 

Hospitals: Evaluating Hospitals’ Adherence to the Culturally and Linguistically 

Appropriate Services Standards” (Weech-Maldonado et al., 2012a) 

•	 The COSMOS Corporation’s Developing a Self-Assessment Tool for Culturally and 

Linguistically Appropriate Services in Local Public Health Agencies: Final Report 

(COSMOS Corporation, 2003) 

•	 SAMHSA’s “Resources Related to Cultural Competence” (SAMHSA, 2016c) 

•	 SAMHSA’s “Appendix C: Tools for Assessing Cultural Competence” in Improving 

Cultural Competence (SAMHSA, 2014a). 

We synthesized the results of the review and identified the evaluation questions that 

corresponded to different elements of the logic models. Our goal was to derive evaluation 

questions that address the process of an organization deciding to implement the National CLAS 

Standards, the planning for and implementation of activities to do so, the resulting outputs, and 

key outcomes and impacts to measure. We decided not to provide setting-specific questions 

because the questions themselves are quite universal, meaning that they can be used in any health 

setting and are relevant regardless of which National CLAS Standards are selected by an HCO 

for implementation. The evaluation questions are summarized below; they are divided into 

questions relevant for process evaluations and those more relevant for impact/outcomes 

evaluations. 

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Process Evaluation Questions 

1. Is there an awareness of the National CLAS Standards? 

a. What is the degree of awareness of the National CLAS Standards within the HCO or 

health care system? 

b. How aware is the HCO or health care system about the accreditation or regulatory 

requirements that align with or can otherwise influence adoption of the National 

CLAS Standards? 

c. To what degree does staff understand the benefits of implementing the National 

CLAS Standards—both for the organization and the individuals it serves? 

2.	 Does the organization have a team tasked with addressing culture/language? 

a.	 Which internal champions and internal stakeholders have been identified to help 

focus organizational efforts on providing culturally competent care? 

b.	 Has the organization appointed one or more committees of internal and external 

stakeholders to oversee the design, planning, and implementation of CLAS-related 

activities in the following areas? 

i.	 Governance, leadership, and workforce 

ii. Communication and language assistance 

iii. Engagement, continuous improvement, and accountability 

c.	 To what extent have diverse viewpoints been incorporated in organizational planning 

and implementation of policies, programs, and services? 

3.	 Does the organization have active and ongoing input from the community? 

a.	 Have outside partners and/or community resources been identified by the HCO or 

health care system to support implementation of the National CLAS Standards? 

b.	 Which community partners have been identified as important stakeholders for 

implementing the National CLAS Standards? 

i.	 To what degree have these partnerships been formalized (e.g., memoranda of 

understanding)? 

c.	 What community resources have been identified? 

i.	 To what extent have community resources been committed to assist with 

implementation? 

d.	 Which funders or funding agencies and accreditation agencies or bodies (e.g., 

JCAHO, NCQA) have been identified to help guide or support CLAS efforts within 

an organization? 

4.	 Has the organization completed a needs assessment with respect to the National CLAS 

Standards? 

a.	 Has an organizational self-assessment of current CLAS-related activities and gaps 

been conducted within the past two years? 

i.	 If so, in what areas (e.g., accessibility of language services)? 

b.	 To what extent do the National CLAS Standards align with the organization’s or 

health care system’s policies and practices that are already in place? 

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c.	 To what extent are the organization’s or health care system’s current strategic 

priorities aligned with the National CLAS Standards? 

5.	 Has the organization developed an implementation plan to address gaps and priorities 

identified? 

a.	 What gaps have been identified, and what prioritization has been made? 

b.	 What opportunities for improvement and actions have been identified to meet the 

National CLAS Standards? 

6.	 Has the organization committed funds or resources for the proposed change? 

a.	 To what extent have the needed resources (e.g., staff, funding) within the HCO or 

health care system and from the community been set aside or designated to 

implement the National CLAS Standards? 

7.	 To what extent has the organization implemented its plan to address identified needs and 

gaps in culturally and linguistically appropriate services? 

a.	 What changes in governance, leadership, and/or workforce have been made to 

facilitate implementation of the National CLAS Standards? 

b.	 What changes in policies and organizational structures have been made to implement 

the National CLAS Standards? 

c.	 What changes in human resource practices have been made to increase recruitment 

and retention of minorities at all levels of the organization? 

d.	 Has a formal training program for staff on cultural and language diversity been 

implemented? 

e.	 What improvements have been made to ensure access to accurate population data, 

particularly by race/ethnicity, primary language, and other minority status 

information? 

8.	 To what extent does the organization collect and use data for CQI? 

a.	 What CQI processes have been put into place? 

b.	 What changes in data collection have been made to improve the collection of, access 

to, and dissemination of accurate population data to assess needs and progress made 

by the organization or health system in aligning its practices to the National CLAS 

Standards? 

Outcomes Evaluation Questions 

In the logic models, we identified the outcomes for both the short term and the longer term 

(at the organizational level and the client or individual level) as a result of the activities 

undertaken to implement the National CLAS Standards. The overarching outcomes question is 

whether the activities undertaken have resulted in changes in access, consumer experience, 

quality of care, and health outcomes. As noted earlier in this chapter, we made the distinction 

between short-term outcomes and longer-term outcomes and impacts. Specifically, questions 

identified for short-term outcomes include changes at the organizational or individual/client 

levels that one would expect to see within 1–2 years of implementation of the National CLAS 

Standards, such as improved access to high-quality language services. Questions related to 

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longer-term outcomes or impacts include changes at the organizational or individual/client levels 

expected to take 3 or more years to realize, such as shifts in organizational culture. 

Below we summarize examples of the evaluation questions for each area. 

Short-Term Outcomes 

For organizations: To what extent has the implementation of the National CLAS Standards 

led or contributed to 

1.	 the use of data on race, ethnicity, sex, sexual orientation, disability status, and language 

to monitor and improve health service delivery? 

2.	 improved two-way communication between providers and clients? 

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

staff? 

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

For clients/individuals: To what extent has implementation of the National CLAS Standards 

resulted in 

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

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

ways? 

3.	 increased consumer understanding of health care treatment options and more-informed 

care decisions? 

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

Longer-Term Outcomes/Impacts 

For organizations: To what extent has the implementation of the National CLAS Standards 

led to a cultural shift in the organization? To what extent has implementation led or contributed 

to 

1.	 improvements in the provision of high-quality services for diverse populations? 

2.	 improved health outcomes for ethnic and minority populations? 

3.	 increased trust and engagement between patients and providers? 

4.	 increased trust and engagement between the community and HCOs? 

5.	 increased equity in access to health services? 

6.	 a reduction in disparities in health outcomes? 

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

population?
 

For clients/individuals: To what extent has implementation of the National CLAS Standards 

led to 

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

2.	 improved satisfaction among individuals seeking health care? 

3.	 increased trust and engagement between individuals seeking care and treatment
 

providers?
 

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

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1.	 increased use of appropriate health care services with regular follow-up and continuing of 

care? 

2.	 increased equity in outcomes of health services? 

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

Process Outcomes and Impact Measures 

Approach 

Our literature search to develop the evaluation questions also identified a number of 

examples of process, outcomes, and impact measures. We augmented that literature review to 

include commissioned reports (e.g., NQF, 2012g); a search of peer-reviewed journal articles; and 

a search of guidance, reports, and measures provided on the websites of leading public entities 

(e.g., AHRQ, HRSA) and private entities, such as the NCQA and JCAHO. We also reviewed the 

2014 Crosswalk between the National CLAS Standards and the JCAHO Hospital Accreditation 

Standards (The Joint Commission, 2014). In addition, OMH provided feedback to inform our 

search strategy. For example, a priority of OMH was that we include in our search reports by the 

NQF and reports relevant to the Cultural Competency Assessment Tool for Hospitals (CCATH) 

and local public health agencies in our search. We also included measures from CAHPS and 

HCAHPS in our review, given OMH’s desire for RAND to leverage the CAHPS measures where 

possible. 

Our overall approach was to identify a range of examples of measures for each setting, 

emphasizing well-constructed and validated measures with some or all of the following 

characteristics: 

•	 assessed cultural competency 

•	 captured language needs or preferences and/or linked to other CLAS-related issues 

•	 documented disparities 

•	 were widely used and plausible for use in a range of HCOs (e.g., small or large) 

−	 inclusive of measures that are used by several different quality reporting systems 

(e.g., sets of measures used by HRSA, NCQA, CMS) 

•	 were previously endorsed in commissioned projects or reports for evaluating disparities 

•	 were validated and/or psychometrically tested 

•	 cut across conditions and/or across settings. 

Although we included some process measures, our focus was on identifying outcome and impact 

measures relevant to evaluating the implementation of the National CLAS Standards. Wherever 

possible, we also sought to identify measures of short-term or intermediate outcomes of health 

care encounters with the HCO. The set of measures identified is intended to illustrate the key 

outcome and impact measures that are salient to the National CLAS Standards; it is not intended 

to be comprehensive. In addition, one of the objectives was to identify measures that would help 

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organizations move to a more consistent set of metrics to facilitate cross-site comparisons and 

meta-analyses. 

It should be noted that for some types of HCOs or settings, well-validated or widely tested 

measures were scarce. In those cases, we identified the best measures that we could find that 

either had been validated to some extent and/or had good face validity. For example, in 

behavioral health, we were unable to find a validated measure of cultural competency and so 

note that there remains a need for the development of such a measure in this area. 

We also sought to identify examples of disparity-sensitive measures for each setting that an 

HCO might use to assess how well it is doing in addressing identified disparities in outcomes. To 

identify disparity-sensitive measures, we drew on a number of sources, such as the Healthcare 

Disparities and Cultural Competency Consensus Standards project (NQF, 2012g), which 

identified disparity-sensitive measures among the existing NQF portfolio of endorsed measures; 

an NQF-commissioned paper by Weissmann et al. (2012) on health care disparities 

measurement; a 2008 NQF report, National Voluntary Consensus Standards for Ambulatory 

Care—Measuring Healthcare Disparities; and examples of recommended measures from 

SAMHSA’s National Behavioral Health Quality Framework (SAMHSA, 2014b). In addition, we 

reviewed the 2015 and 2016 lists of JCAHO Accountability Measures (Joint Commission, 

undated[a]), which, although not explicitly identified as disparity-sensitive, OMH and RAND 

agreed were important to include.7 

7 Specifically, we added information for hospitals about selected JCAHO accountability measures that we felt were 

particularly CLAS-salient (e.g., venous thromboembolism [VTE], immunization, substance abuse). 

Lastly, OMH desired a measure of workforce diversity that would enable HCOs to assess 

whether the diversity of their workforce (e.g., leadership [board, executive leadership, midmanagement diversity] and clinical and frontline staff [e.g., the diversity of hospitals’ nursing 

staff and hospitalists]) matches the diversity in their organization’s patient population. We 

conducted a literature search on this topic and did not identify any standard measures of 

workforce diversity. However, we encourage HCOs to consider the metrics that might inform 

their understanding of how well their workforce represents the diversity seen in their patient 

population. 

Measures Identified 

Tables 7.1–7.5 present an overview of the identified measures (including measure title and 

general description), organized according to setting. If the measure is relevant to more than one 

setting, it is classified as cross-cutting. For each setting, we also include examples of disparitysensitive measures that an HCO may use to assess how well it is doing in addressing identified 

disparities in outcomes. In Appendixes B–F, we provide further information about each measure, 

including the area of focus, the source, the wording of specific items, any relevant notes, and a 

reference to the measure set. 

60
 
 

 

 

Table 7.1. Cross-Cutting Measures 

Measure(s) Description 

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 CAHPS Clinician/Group Survey (CG-CAHPS) that 

includes the following domains: patient-provider communication; complementary 

and alternative medicine; experiences of discrimination due to 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. 

Clinician/group’s 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 selfmanagement, 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. 

Patients receiving language services 

supported by qualified language 

services providers 

This measure is used to assess the percentage of patients with limited English 

proficiency (LEP) receiving both initial assessment and discharge instructions from 

assessed and trained interpreters or from bilingual providers and bilingual 

workers/employees who have been 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. 

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 in which they prefer to receive care and the extent to which this 

information is recorded. 

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. 

Communication Climate 

Assessment Toolkit (C-CAT) 

C-CAT, which has been extensively validated in diverse health care organizations 

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 

complements CAHPS assessments, documents compliance with Title VI culturally 

and linguistically appropriate services standards, and is invaluable in meeting 

JCAHO’s patient-centered communication standards. 

61
 
Table 7.2. Ambulatory Care Measures 

Measure(s) Description 

Consumer Assessment of 

Healthcare Providers and 

Systems (CAHPS) Cultural 

Competence Item 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 due to 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; and 

equitable treatment. 

Consumer Assessment of 

Healthcare Providers and 

Systems (CAHPS) 

Clinician/Group Survey (CGCAHPS) 

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. 

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. 

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. 

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 population, ages 18 and 

older. Excludes obstetric admissions and transfers from other institutions. 

Diabetes short-term 

complications admission 

rate 

Admissions for a principal diagnosis of diabetes with short-term complications 

(ketoacidosis, hyperosmolarity, or coma) per 100,000 population, ages 18 and older. 

Excludes obstetric admissions and transfers from other institutions. 

62
 
 

Table 7.3. Hospital Measures 

Measure(s) Description 

Hospital Consumer Assessment of 

Healthcare Providers and Systems 

(HCAHPS) Survey 

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and 

Systems) 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. 

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 CAHPS Hospital Survey 

(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. 

Cultural Competency Assessment Tool for 

Hospitals (CCATH) 

The Cultural Competency Assessment Tool for Hospitals (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 quality 

improvement, data collection on inpatient population, data collection on 

service area, and community representation. 

JCAHO’s Hospital Accreditation Standards 

and Elements of Performance 

JCAHO standards are the basis of an objective evaluation process that can 

help health care organizations 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. JCAHO’s state-of-the-art standards set expectations for organizational 

performance that are reasonable, achievable, and surveyable. JCAHO has 

several accreditation standards that directly or indirectly support the 

provision of culturally and linguistically appropriate services. 

The Joint Commission 2016 Accountability 

Measure List for Accreditation ChartAbstracted Process Measures 

The Joint Commission categorizes its process performance measures into 

accountability and non-accountability 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 quality improvement, exploration, 

and learning within individual health care organizations and are good advice 

in terms of appropriate patient care. The accountability measures cover 

areas including inpatient psychiatric services, venous thromboembolism 

(VTE) care, stroke care, perinatal care, immunization, tobacco treatment, 

and substance use. 

63
 
Measure(s) Description 

 

 

 

Disparity-sensitive measures or CLASsalient measures 

Hospital 30-day, all-cause, riskstandardized readmission rate (RSRR) 

following pneumonia hospitalization 

The measure estimates a hospital-level 30-day, all-cause risk-standardized 

readmission rate (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 ages 

65 or older who are enrolled in fee-for-service (FFS) Medicare and 

hospitalized in non-federal hospitals. 

Median time to ECG Median time from emergency department arrival to ECG (performed in the 

emergency department prior to transfer) for acute myocardial infarction 

(AMI) or chest pain patients (with probable cardiac chest pain). 

Hospital 30-day, all-cause, riskstandardized mortality rate (RSMR) 

following coronary artery bypass graft 

(CABG) surgery 

The measure estimates a hospital-level risk-standardized mortality rate 

(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 Fee-forService (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. 

Risk-adjusted deep sternal wound 

infection 

Percentage of patients ages 18 and older undergoing isolated CABG 

procedures who develop mediastinitis or deep sternal wound infections 

within 30 days postoperatively 

64
 
 

Table 7.4. Behavioral Health Measures 

Measure(s) Description 

Experience of Care and Health Outcomes 

(ECHO) survey 

The Experience of Care and Health Outcomes (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: 

managed care organizations (MCOs) and managed behavioral healthcare 

organizations (MBHOs). 

Disparity-sensitive measures or CLASsalient 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. 

Initiation and engagement of alcohol 

and other drug dependence treatment 

The 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. 

a. Percentage of patients who initiated treatment within 14 days of the 

diagnosis 

b. 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. 

Antidepressant medication 

management (AMM) 

The percentage of patients ages 18 and older with a diagnosis of major 

depression and who were newly treated with antidepressant medication 

who remained on an antidepressant medication treatment. Two rates are 

reported. 

a. 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). 

b. 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). 

Thirty-day all-cause unplanned 

readmission following psychiatric 

hospitalization in an inpatient 

psychiatric facility (IPF) 

This facility-level measure estimates an all-cause, unplanned, 30-day riskstandardized readmission rate (RSRR) for adult Medicare Fee-for-Service 

(FFS) patients with a principal discharge diagnosis of a psychiatric disorder 

or dementia/Alzheimer’s disease. 

65
 
Table 7.5. Public Health Measures 

Measure(s) Description 

Developing a Self-Assessment Tool for 

Culturally and Linguistically Appropriate 

Services (CLAS) in Local Public Health 

Agencies (LPHAs) 

This self-assessment tool for Local Public Health Agencies (LPHAs) is 

aimed to offer sound measures of culturally and linguistically appropriate 

services. The term LPHA is defined as a publicly funded entity (i.e., local 

health department, local board of health, 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 overlaps, not all items from each instrument are presented in this 

document. In Appendix F 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. See Appendix F for a list of the 

complete instruments, including survey questions and multiple-choice 

items. 

Consumer Assessment of Healthcare 

Providers and Systems (CAHPS) 

Clinician/Group Survey (CG-CAHPS) 

Consumer Assessment of Healthcare Providers and Systems (CAHPS) 

surveys ask consumers and patients to report on and evaluate their 

experiences with health care. The CAHPS Clinician/Group Survey (CGCAHPS) assesses patients’ experiences with health care providers and 

staff in doctors’ offices. 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. 

Disparity-sensitive measures or CLASsalient 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 is 

collected via the CAHPS 5.0H adults survey for Medicare, Medicaid, and 

commercial populations. It is reported as two separate rates stratified by 

age: ages 18–64 and 65 and older. 

Asthma emergency department visits The percentage of patients with asthma who have one or more visits to the 

emergency room for asthma during the measurement period 

Depression screening, adolescents 18 

years of age 

The percentage of adolescents 18 years of age who had a screening for 

depression using a standardized tool 

Preventive care and screening: 

tobacco use: screening and cessation 

intervention 

The 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 

66
 
67

Chapter Eight. Conclusions 

The National CLAS Standards were developed by OMH, in collaboration with federal and 

nonfederal partners across the country, to provide meaningful and practical guidance to health 

organizations and HCOs about delivering culturally and linguistically appropriate services. The 

resulting 15 National CLAS Standards are intended to advance health equity, improve quality, 

and help eliminate health care disparities by providing a blueprint for individuals and HCOs to 

implement the National CLAS Standards.

OMH also recognized the importance of establishing an evaluation framework to guide longterm efforts to assess the implementation of the National CLAS Standards—to describe National 

CLAS Standards adoption and implementation and to examine the relationship between 

implementation and its associated outcomes. This report describes RAND’s approach to 

developing this evaluation framework. The preceding chapters provided information about the 

development of (1) the National CLAS Standards theory of change and setting-specific logic 

models, (2) evaluation questions that test the theory of change and the corresponding methods,

and (3) indicators8

8 The terms indicator and measure can be used interchangeably. In this report, we chose to use the term measure to 

be inclusive of the wide range of types of measures, from the CAHPS measures to such disparity-sensitive clinical 

measures as median time to ECG. 

or measures and supporting data metrics to support the National CLAS 

Standards theory of change.

The evaluation framework, logic models, and evaluation questions and measures presented in 

this report are intended to provide a systematic approach for gathering data to evaluate the 

effectiveness of the National CLAS Standards. OMH’s intent behind supporting the development 

of an evaluation framework was not only to alleviate the burden on health organizations in 

conducting an evaluation but also to facilitate the use of similar research questions and metrics 

across health organizations and HCOs, which may generate more-comparable data on the 

importance and relevance of the National CLAS Standards in helping to address health inequities 

and eliminate health care disparities. As a result, we developed a companion toolkit titled

Evaluation of the National CLAS Standards: Tips and Resources (Williams et al., forthcoming).

While this report provides details on the methodologic approach for developing key elements 

of the evaluation framework, the interactive toolkit is designed to support health organizations in 

their efforts to implement the National CLAS Standards and to improve their capacity to evaluate 

their approach. The toolkit focuses on translating the overall evaluation framework into elements 

that can be adopted by individual organizations for their own approach. Users can click on links

and jump to sections that are most relevant to them based on their experience with evaluation, 

their health care setting, or their measurement needs. They can also read short case studies of 

 
68

how similar organizations have implemented and evaluated the National CLAS Standards. The 

toolkit is organized into four sections:

• information about the toolkit, who should use it, and what it is designed to help 

organizations do

• seven steps for implementing and evaluating the National CLAS Standards

• context and details relevant for evaluating specific National CLAS Standards

• an extensive list of relevant resources and information on potential data sources and 

metrics that may be used by organizations in conducting their evaluation.

The focus of the toolkit is on evaluation of the National CLAS Standards. Thus, it does not 

include extensive information on how to identify, design, or implement activities and approaches 

that an organization may pursue to address the National CLAS Standards. The reader is instead 

directed to a number of additional resources offered by HHS OMH and the Think Cultural 

Health website (HHS OMH, undated[b]).

As our nation grows increasingly diverse, all health organizations and HCOs will need to be 

poised to ensure that the care they provide is not only of high quality but is also equitable and 

responsive to individuals with diverse cultural experiences, beliefs, and preferences and with a 

wide range of language and literacy skills. The National CLAS Standards call attention to 15 

areas that, if addressed, hold great promise for helping health organizations and HCOs address 

current barriers to providing equitable care. The evaluation framework outlined in this report and 

in the companion toolkit is intended to support health organizations in their efforts. By providing 

a conceptual framework, logic models, research questions, and measures that are widely 

collected, health organizations can assess the impact of their efforts more easily, both on the 

individuals they serve and on their organizations. Such evaluations provide valuable data and 

insights that inform CQI efforts within a given health organization and collectively can inform 

and help to shape systems-level change to provide culturally and linguistically appropriate care 

and services.
69

Appendix A. List of Technical Advisory Group Members

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

Evaluation

• Helen Burstin, M.D., M.P.H., FACP, chief scientific officer, the 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, NewYorkPresbyterian 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, CMS

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

of Health Equity

• 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.
 

 

 

 

Appendix B. Cross-Cutting Measures
 

When we developed the process and outcomes/impact measures described in Chapter Seven, 

we classified those measures that are relevant to more than one setting as cross-cutting. In Table 

B.1, we list the six cross-cutting measures identified, along with a brief description, area of 

focus, source, the settings in which the measure is applicable, and the reference for each 

measure. Table B.2 provides additional detail for each measure and lists the items that comprise 

each measure. 

70
 
 

 

 

Table B.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 CAHPS Clinician/Group Survey (CGCAHPS) that includes the following domains: 

patient-provider communication; complementary 

and alternative medicine; experiences of 

discrimination due to 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 

National Quality 

Forum (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 Table B.2 for 

list of measures. 

NQF #1904 

Measure 

Specifications 

(NQF, 2012c) 

Endorsement 

Summary – 

Healthcare 

Disparities and 

Cultural 

Competency 

Measures 

(NQF, 2012f) 

Clinician/group’s 

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 CAHPS Clinician/Group 

Survey (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. 

See Table B.2 for 

list of measures. 

NQF #1902 

Measure 

Specifications 

(NQF, 2012d) 

Endorsement 

Summary – 

Healthcare 

Disparities and 

Cultural 

Competency 

Measures 

(NQF, 2012f) 

Patients receiving 

language services 

supported by 

qualified language 

services providers 

This measure is used to assess the percentage of 

patients with limited English proficiency (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 

Language services NQF #1821—L2: 

Patients receiving 

language services 

supported by 

qualified language 

services providers 

(measure steward: 

George 

Washington 

University 

Applicable to all 

settings. 

NQF #1821 L2 

Measure 

Specifications 

(NQF, 2012b) 

NQF, 2012f 

71
 
 

 

Measure(s) Description Area of Focus Source/ID Notes Reference 

during critical times in a patient’s health care 

experience. 

Department of 

Health Policy) 

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 1824-L1A 

Measure 

Specifications 

(NQF, 2012a) 

Endorsement 

Summary –
	

Healthcare 

Disparities and 

Cultural 

Competency 

Measures 

(NQF, 2012f) 

Cultural 

Competency 

Implementation 

Measure 

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, 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. 

See Table B.2 for 

list of measures. 

These measures 

have yet to be 

tested/validated. 

NQF #1919 

Measure 

Specifications 

(NQF, 2012e) 

Endorsement 

Summary –
	

Healthcare 

Disparities and 

Cultural 

Competency 

Measures 

(NQF, 2012f) 

Communication 

Climate 

Assessment 

Toolkit (C-CAT) 

C-CAT, which has been extensively validated in 

diverse health care organizations 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 

Communication 

climate 

C-CAT survey 

(measure steward: 

University of 

Colorado Center 

for Bioethics and 

Humanities) 

Applicable to all 

settings. See 

Table B.2 for list 

of measures. 

C-CAT Surveys 

(Center for 

Bioethics and 

Humanities, 

undated) 

Endorsement 

Summary –
	

Healthcare 

Disparities and 

Cultural 

Competency 

Measures 

72
 
 

 

 

 

 

Measure(s) Description Area of Focus Source/ID Notes Reference 

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 CCAT provides valuable information regarding needs 

assessments and meeting local and national 

standards. Organizations using C-CAT find that it 

complements CAHPS assessments, documents 

compliance with Title VI culturally and linguistically 

appropriate services standards, and is invaluable in 

meeting The Joint Commission’s patient-centered 

communication standards. 

(NQF, 2012f) 

Table B.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 CAHPS 

Clinician/Group Survey (CG-CAHPS) that includes the following domains: patient-provider communication; complementary
 

and alternative medicine; experiences of discrimination due to 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. 

(MEASURES BELOW: 5 item 

sets, 2 composite measures) 

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, 

73
 
 

 

 

 

Measures Items 

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? 

Experiences of 

discrimination due to 

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 truth-telling 

(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?
 

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/group’s 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 

CAHPS Clinician/Group Survey (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. 

74
 
 

 

 

 

 

 

 

Measures Items 

(MEASURES BELOW: 5 item 

sets, 1 composite measure) 

Measures can be calculated at the individual clinician level or at the group (e.g., practice, clinic) level. 

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? (Never)
 

HL2: In the last 12 months, how often did this provider use medical words you did not understand? (Never)
 

HL3: In the last 12 months, how often did this provider talk too fast when talking with you? (Always)
 

HL4: In the last 12 months, how often did this provider use pictures, drawings, models, or videos to explain things to you? 

(Always)
 

HL5: In the last 12 months, how often did this provider ignore what you told him or her? (Never)
 

HL6: In the last 12 months, how often did this provider interrupt you when you were talking? (Never)
 

HL7: In the last 12 months, how often did this provider show interest in your questions and concerns? (Always)
 

HL8: In the last 12 months, how often did this provider answer all of your questions to your satisfaction? (Always)
 

HL9: In the last 12 months, how often did this provider give you all the information you wanted about your health? (Always)
 

HL10: In the last 12 months, how often did this provider encourage you to talk about all your health questions or concerns? 

(Always)
 

HL17: In the last 12 months, how often did this provider use a condescending, sarcastic, or rude tone or manner with you?
 

(Never)
 

Disease self-management HL11: In the last 12 months, did you see this provider for a specific illness or for any health condition? [screener for HL12–
	

17] (NA)
 

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? (Yes)
 

HL13: In the last 12 months, how often were these instructions easy to understand? (Always)
 

HL14: In the last 12 months, how often did this provider ask you to describe how you were going to follow these 

instructions? (Always)
 

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? 

(Always)
 

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? (Always)
 

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?
 

[screener for HL19–25] (NA)
 

HL20: In the last 12 months, did this provider give instructions about how to take your medicines? (Yes)
 

HL21: In the last 12 months, how often were these instructions about how to take your medicines easy to understand? 

(Always)
 

HL22: In the last 12 months, did this provider explain the possible side effects of your medicines? (Yes)
 

HL23: In the last 12 months, how often were these explanations easy to understand? (Always)
 

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? (Yes)
 

HL25: In the last 12 months, how often was the written information you were given easy to understand? (Always)
 

HL26: In the last 12 months, how often did this provider suggest ways to help you remember to take your medicines?
 

(Always)
 

75
 
 

Measures	 Items 

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? [screener for Core 22] (NA)
 

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? (NA) [screener for HL26]
 

HL26: In the last 12 months, how often were the results of your blood test, X-ray, or other test easy to understand? (Always)
 

Communication about forms HL27: In the last 12 months, did you sign any forms at this provider’s office? [screener for HL28] (NA)
 

HL28: In the last 12 months, how often did someone explain the purpose of a form before you signed it? (Always)
 

HL29: In the last 12 months, did you fill out any forms at this provider’s office? [screener for HL30–31] (NA)
 

HL30: In the last 12 months, how often were you offered help to fill out a form at this provider’s office? (Always)
	

HL31: In the last 12 months, how often were the forms from this provider’s office easy to fill out? (Always)
	

Cultural Competency 

Implementation Measure 

(MEASURES BELOW: 12 

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, 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 health care organizations across a range of health care settings, 

including hospitals, health plans, community clinics, and dialysis organizations. Information from the survey can be used for 

quality improvement, to provide information that can help health care organizations 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. 

Cultural Competency 

Implementation Measure– 

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 measurable 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? 

Cultural Competency 

Implementation Measure– 

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) from the community? 

4.	 used a committee of current diverse staff to develop strategies for recruitment, retention, and promotion of staff that 

76
 
Measures	 Items 

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? 

Cultural Competency 

Implementation Measure– 

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? 

(Check all that apply)
 

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? 

Cultural Competency 

Implementation Measure– 

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? 

Cultural Competency 

Implementation Measure– 

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 

77
 
 

Measures	 Items 

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? 

Cultural Competency 

Implementation Measure– 

Subdomain: Language 

Access 

Has your organization: 

1.	 reviewed its language assistance resource policies to ensure that your organization is providing language assistance 

to LEP persons 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 LEP individuals—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, 

78
 
Measures	 Items 

assist with transfers within a facility)? 

Cultural Competency 

Implementation Measure– 

Subdomain: Clinical 

Encounter 

Within the past 12 months, how often has your organization: 

•	 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: 

•	 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: 

•	 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: 

•	 implemented comprehensive care plans that address the physical, cultural, and social needs of the patient, including 

cultural background, religion, and spiritual belief system? 

Cultural Competency 

Implementation Measure– 

Subdomain: Training 

Commitment and Content 

Has your organization: 

1.	 reviewed training materials and programs used to provide cultural competence training? 

2.	 assessed the organization’s 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 of the organization
 

receive training that is effective, relevant, and up to date?
 

4.	 had human resource managers assess the qualifications and competency 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? 

(Check all that apply)
 

9.	 provided training and coaching to new staff to increase cultural competency awareness, knowledge, and skills? 

(Check all that apply)
 

10. provided training and coaching to current staff to increase cultural competency awareness, knowledge, and skills? 

(Check all that apply)
 

Cultural Competency 

Implementation Measure– 

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?
 

79
 
 

Measures	 Items 

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? 

Cultural Competency 

Implementation Measure– 

Subdomain: Collection of 

Patient Cultural 

Competency-Related 

Information 

Has your organization: 

1.	 reviewed patient data on race/ethnicity to ensure that you are collecting this information using OMB categories as 

modified by HRET231?
 

2.	 reviewed data from health records to ensure that data on an individual patient’s race and ethnicity and primary written 

and spoken language are collected? 

3.	 reviewed data from your organization’s management information system to ensure that 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 and ethnicity and 

primary written and spoken language into management information systems? 

7.	 updated information on patients’ race and ethnicity and primary written and spoken language in the last 12 months? 

Cultural Competency 

Implementation Measure– 

Subdomain: Quality 

Improvement 

Has your organization: 

1.	 identified NQF-endorsed performance measures to collect and use for quality improvement 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 quality improvement 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 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? 

5.	 implemented quality improvement strategies or projects focused on providing more culturally competent care and 

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

Cultural Competency 

Implementation Measure– 

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? 

80
 
 81
 

 

 

Measures Items 

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?
 

Communication Climate 

Assessment Toolkit (C-CAT) 

C-CAT, which has been extensively validated in diverse health care organizations nationally, provides a 360-degree 

organizational assessment using coordinated patient, staff, and leadership surveys, as well as an organizational workbook 

(MEASURES BELOW: 7 

measures using items across 5 

different surveys: staff, patient, 

pediatric patient, executive, and 

organizational) 

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 

complements CAHPS assessments, documents compliance with Title VI culturally and linguistically appropriate services 

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 C-CAT 

Site score on the measure derived from the domain of “leadership commitment” of the C-CAT, 0–100 

Cross-cultural 

communication measure 

derived from the crosscultural 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 CCAT 

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 

Site score on “individuals’ engagement” domain of patient-centered communication, per the C-CAT, 0–100 
 82
 

Measures Items 

domain of the C-CAT 

Language services measure 

derived from the language 

services domain of the CCAT 

Site score on the domain of “language services” of the C-CAT, 0–100 
 

 

 

 

 

 

Appendix C. Ambulatory Care Measures
 

In developing the process and outcomes/impact measures described in Chapter Seven, we identified measures relevant to the 

ambulatory care setting. In Table C.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 C.2 provides additional detail for each measure and summarizes the relevant items that comprise each measure. 

Table C.1. Ambulatory Care Measures 

Measure(s) Description Area of Focus Source/ID Notes Reference 

Consumer 

Assessment of 

Healthcare 

Providers and 

Systems (CAHPS) 

Cultural 

Competence Set 

Consumer Assessment of Healthcare Providers 

and Systems (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 due to 

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; and 

equitable treatment 

Cultural 

competency 

CAHPS Cultural 

Competence Item 

Set 

See Table C.2 for 

list of measures. 

CAHPS Cultural 

Competence Set 

(AHRQ, 2012) 

WeechMaldonado et al., 

2012b 

83
 
84
 

Measure(s) Description Area of Focus Source/ID Notes Reference 

Consumer 

Assessment of 

Healthcare 

Providers and 

Systems 

Clinician/Group 

Survey (CGCAHPS) 

Consumer Assessment of Healthcare Providers 

and Systems (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 CGCAHPS 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 CAHPS 

Clinician/Group 

Survey (CGCAHPS) 

See Table C.2 for 

list of measures. 

CAHPS 

Clinician/Group 

Survey 

(AHRQ, 2013b) 

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 

NQF #18 

(measure steward: 

National 

Committee of 

Quality Assurance 

[NCQA]) 

BP < 150/90 in 

patients ages 60 

and older without 

diabetes 

considered 

controlled in 

HEDIS. 

This is a disparitysensitive 

measure. 

NQF Quality 

Positioning 

System 

Measure 

Specifications 

(search: “18”) 

(NQF, undated) 

Healthcare 

Disparities and 

Cultural 

Competency 

Consensus 

Standards: 

DisparitiesSensitive Measure 

Assessment 

(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. 

NQF Quality 

Positioning 

System Measure 

Specifications 

(search: “59” or 

“575”) 
Measure(s) Description Area of Focus Source/ID Notes Reference 

This is a disparitysensitive 

measure. 

(NQF, undated) 

Healthcare 

Disparities and 

Cultural 

Competency 

Consensus 

Standards: 

DisparitiesSensitive Measure 

Assessment 

(NQF, 2012g) 

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 population, ages 18 and 

older. Excludes obstetric admissions and transfers 

from other institutions. 

Patient safety, 

primary prevention 

NQF #638 

(measure steward: 

Agency for 

Healthcare 

Research and 

Quality [AHRQ]) 

This is a disparitysensitive 

measure. 

NQF Quality 

Positioning 

System 

Measure 

Specifications 

(search: “638”) 

(NQF, undated) 

Healthcare 

Disparities and 

Cultural 

Competency 

Consensus 

Standards: 

DisparitiesSensitive Measure 

Assessment 

(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 population, 

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 Quality 

Positioning 

System 

Measure 

Specifications 

(search: “272”) 

(NQF, undated) 

Healthcare 

Disparities and 

Cultural 

85
 
 

Measure(s) Description Area of Focus Source/ID Notes Reference 

Competency 

Consensus 

Standards: 

DisparitiesSensitive Measure 

Assessment 

(NQF, 2012g) 

Table C.2. Ambulatory Care Measures: Additional Details 

Measures Items 

Consumer Assessment of 

Healthcare Providers and 

Systems (CAHPS) Cultural 

Competence Set 

(MEASURES BELOW: 8 

composites) 

Consumer Assessment of Healthcare Providers and Systems (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 due to 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 decision-making; and 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? 

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 

86
 
 87
 

 

Measures Items 

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 decision-making 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?
 

Consumer Assessment of 

Healthcare Providers and 

Systems (CAHPS) 

Clinician/Group Survey 

Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys ask consumers and patients to report on
 

and evaluate their experiences with health care. The CAHPS Clinician/Group Survey (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 

(SELECTED MEASURES the provider.
 

BELOW) 

Getting timely appointments, 

care, and information 

Patient got an appointment for urgent care as soon as needed.
 

Patient got an appointment for non-urgent care as soon as needed.
 

Patient got an answer to medical question the same day he/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.
 
 

 

 

 

 

 

 

Appendix D. Hospital Measures
 

In developing the process and outcomes/impact measures described in Chapter Seven, we identified measures relevant to the 

hospital setting. In Table D.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 D.2 provides 

additional detail for each measure and summarizes the relevant items that comprise each measure. 

Table D.1. Hospital Measures 

Measure(s) Description Area of Focus Source/ID Notes Reference 

Hospital Consumer 

Assessment of 

Healthcare 

Providers and 

Systems 

(HCAHPS) Survey 

The HCAHPS (Hospital Consumer Assessment of 

Healthcare Providers and Systems) 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. 

Cultural 

competency 

HCAHPS See Table D.2 for 

list of measures. 

HCAHPS Survey 

(AHRQ, 2014) 

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 CAHPS Hospital Survey (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. 

HCAHPS Health 

Literacy Item Set 

(AHRQ, 2012) 

88
 
Measure(s)	 Description Area of Focus Source/ID Notes Reference 

Cultural 

Competency 

Assessment Tool 

for Hospitals 

(CCATH) 

The Cultural Competency Assessment Tool for 

Hospitals (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 quality 

improvement, 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 

(Institute for 

Diversity and 

Health Equity, 

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 health care 

organizations measure, assess, and improve 

performance. The standards focus on important 

patient, individual, or resident care and organization 

functions that are essential to providing safe, highquality 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. 

Culturally and 

linguistically 

appropriate 

services 

JCAHO 

Accreditation 

Standards 

See Table D.2 for 

list of measures. 

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 

(The Joint 

Commission, 

2014) 

The Joint 

Commission: 2016 

Accountability 

Measure List for 

Accreditation 

Chart-Abstracted 

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: 

Accountability	 JCAHO 

Accountability 

Measures 

See Table D.2 for 

list of measures. 

2016 

Accountability 

Measure List for 

Accreditation 

Chart-Abstracted 

Process Measures 

(The Joint 

Commission, 

89
 
90
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measure(s) Description Area of Focus Source/ID Notes Reference

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 quality

improvement, exploration, and learning within 

individual health care organizations and are good 

advice in terms of appropriate patient care. The

accountability measures cover areas including

inpatient psychiatric services, venous

thromboembolism (VTE) care, stroke care, perinatal

care, immunization, tobacco treatment, and substance

use.

2016)

Disparity-Sensitive

Measures or 

CLAS-Salient

Measures

Hospital 30-

day, all-cause

riskstandardized

readmission

rate (RSRR) 

following

pneumonia 

hospitalization

The measure estimates a hospital-level 30-day, allcause risk-standardized readmission rate (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

fee-for-service (FFS) Medicare hospitalized in nonfederal hospitals.

Patient safety,

care

coordination

NQF #506,

#505, #695,

#1891, #2515,

#1551 (measure

steward:

Centers for

Medicare &

Medicaid

Services)

Also available for

AMI, PCI, COPD,

HF, CABG,

THA/TKA

This is a disparitysensitive

measure.

NQF Quality 

Positioning

System

Measure

Specifications

(search: “506,” 

“505,” ”695,” 

”1891,” ”2515,” or 

”1551”)

(NQF, undated)

Commissioned

Paper: Healthcare

Disparities

Measurement

(Weissman et al.,

2012)

Median time to

ECG

Median time from emergency department arrival to

ECG (performed in the ED prior to transfer) for acute

myocardial infarction (AMI) or chest pain patients (with 

probable cardiac chest pain).

Prevention and

treatment

NQF #289

(measure

steward:

Centers for

Medicare &

Medicaid

NQF Quality 

Positioning

System Measure

Specifications

(search: “289”)

(NQF, undated)
Measure(s) Description Area of Focus Source/ID Notes Reference 

Services) 

Hospital 30­

day, all-cause, 

riskstandardized 

mortality rate 

(RSMR) 

following 

coronary 

artery bypass 

graft (CABG) 

surgery 

The measure estimates a hospital-level riskstandardized mortality rate (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 Fee-forService (FFS) patients ages 65 and older and was 

tested in all-payer patients ages 18 years 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: 

Centers for 

Medicare & 

Medicaid 

Services) 

Also available for 

AMI, COPD, HF, 

pneumonia 

This is a disparitysensitive 

measure. 

NQF Quality 

Positioning 

System Measure 

Specifications 

(search: “2558,” 

“230,” “1893,” 

“229,” or “468”) 

(NQF, undated) 

Commissioned 

Paper: Healthcare 

Disparities 

Measurement 

(Weissman et al., 

2012) 

Risk-adjusted 

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 Quality 

Positioning 

System Measure 

Specifications 

(search: “130”) 

(NQF, undated) 

Commissioned 

Paper: Healthcare 

Disparities 

Measurement 

(Weissman et al., 

2012) 

NOTE: PCI = percutaneous coronary intervention. COPD = chronic obstructive pulmonary disease. HF = heart failure. THA/TKA = total hip arthroplasty/total knee 

arthroplasty. 

91
 
 

 

 

 

 

 

 

Table D.2. Hospital Measures: Additional Details 

Measures Items 

Hospital Consumer Assessment 

of Healthcare Providers and 

Systems (HCAHPS) Survey 

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) 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. 

(SELECTED MEASURES 

BELOW) 

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.
 

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 

CAHPS Hospital Survey (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.
 

(MEASURES BELOW: 6 item 

sets, 2 composite measures) 

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. 

92
 
Measures Items 

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.
 

Communication about tests 

(Note: H-HL20 through HHL23 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, HHL28, 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 gave 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.
 

Cultural Competency 

Assessment Tool for Hospitals 

(CCATH) 

The Cultural Competency Assessment Tool for Hospitals (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
 

93
 
Measures Items 

(MEASURES BELOW: 12 

scales) 

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 quality improvement, 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 the discharge planning? (1b) 

Does the hospital accommodate the ethnic/cultural dietary preferences of inpatients? (1c) 

Does the hospital tailor patient educational materials for different cultural and language groups? (1d) 

Does the hospital tailor patient clinical assessments for different cultural and language groups? (1e) 

Human resources practices Which of the following benefits are available to staff?
 

-Formal mentoring program (5a)
 

-Management training (5b)
 

-Tuition assistance or tuition reimbursement for ongoing education (5c) 

-Personal counseling or employee assistance programs (5d)
 

-Flexible benefits, such as domestic partner benefits, family illness, death, and personal leave policies that accommodate 

alternative definitions of family (5e)
 

-Affinity (networking) groups for racial/ethnic minority staff (5f)
 

-Work/life balance programs, such as flex time, job-sharing or telecommuting, or child or elder care (5g)
 

Diversity training Does this hospital have a formal and ongoing training program on cultural and language diversity? (9)
 

Does the staff involved in the formal complaint and grievance process receive formal training in conflict resolution? (26a)
 

Does the staff involved in the formal complaint and grievance process receive formal training about cultural or language 

differences? (26b)
 

Availability of interpreter 

services 

Are interpreter services available for inpatients in Spanish? (12a) 

Are interpreter services available for inpatients in Chinese? (12b) 

Are interpreter services available for inpatients in Vietnamese? (12c) 

Are interpreter services available for inpatients in Korean? (12d)
 

Are interpreter services available for inpatients in Tagalog? (12e) 

Interpreter services policies Does this hospital have a written policy and procedures about the use of bilingual staff as interpreters? (14a) 

Does this hospital have a written policy and procedures about the use of face-to-face professional interpreters? (14b) 

Does this hospital have a written policy and procedures about the use of face-to-face volunteer interpreters? (14c) 

Does this hospital have a written policy and procedures about the use of family or friends as interpreters? (14e) 

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? (13) 

Does the hospital require an assessment of interpreter fluency in translating medical terms and procedures? (15a) 

Does the hospital require an assessment of interpreter accuracy and completeness? (15b) 

Translation of written 

materials 

What types of written materials does this hospital routinely provide to inpatients in languages other than English?
 

-Informed consent statements? (17a)
 

-Medication instructions? (17b)
 

-Discharge planning instructions? (17c) 

-Patient advance directives? (17d) 

94
 
Measures Items 

-Health education material? (17e)
 

-Does this hospital post signs providing directions in languages other than English? (19)
 

Leadership and strategic 

planning 

Does this hospital's statement of strategic goals include specific language about recruitment of a culturally diverse 

workforce? (20a) 

Does this hospital's statement of strategic goals include specific language about retention of a culturally diverse workforce?
 

(20b) 

Does this hospital's statement of strategic goals include specific language about the provision of culturally appropriate 

patient services? (20c) 

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

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

(22a) 

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? (27)
 

Performance management 

systems and QI 

Does the employee satisfaction survey include measures of diversity climate? (8) 

Is the following assessment conducted at least once each year:
 

-Accessibility of interpreter services? (23a)
 

-Racial/ethnic differences in inpatient service use? (23b)
 

-Racial/ethnic differences in inpatient assessments of care (satisfaction)? (23c)
 

Data collection on inpatient 

population 

Does this hospital collect any ethnicity or racial data on individuals receiving inpatient services? (2) 

Does this hospital collect data on the preferred language for individuals receiving inpatient services? (3) 

Data collection on service 

area 

Does this hospital track changes in the race or ethnicity of its workforce? (6) 

Does this hospital collect or receive any of the following data on the population residing in the service area? 

-Race/ethnicity (24a) 

-Languages spoken (24b) 

-Income levels (24c) 

-Education levels (24d) 

-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) (24e) 

-Utilization of health screening services (mammograms, prostate screening exams, pap smears) (24f) 

Community representation Are community representatives routinely involved in the planning and design of inpatient services for culturally diverse 

populations? (25a) 

Are community representatives routinely involved in the evaluation of existing services for culturally diverse populations? 

(25b) 

The Joint Commission Hospital 

Accreditation Standards and 

Elements of Performance 

(SELECTED MEASURES 

BELOW) 

Joint Commission standards are the basis of an objective evaluation process that can help health care organizations 

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.
 

95
 
 

Measures Items 

The hospital compiles and 

analyzes data (PI.02.01.01) 

The hospital improves 

performance on an ongoing 

basis (PI.03.01.01) 

EP 4: The hospital analyzes and compares internal data over time to identify levels of performance, patterns, trends, and 

variations. 

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. This data includes 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 

The Joint Commission: 2016 

Accountability Measure List for 

Accreditation Chart-Abstracted 

Process Measures 

(SELECTED MEASURES 

BELOW) 

The Joint Commission categorizes its process performance measures into accountability and non-accountability 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 quality improvement, exploration, 

and learning within individual health care organizations and are good advice in terms of appropriate patient care. The 

accountability measures cover areas including inpatient psychiatric services, venous thromboembolism (VTE) care, stroke 

care, perinatal care, immunization, tobacco treatment, and substance use. Here we highlight measures in VTE care and 

substance use. 

Venous Thromboembolism 

(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 

96
 
 

 

 

 

 

 

Appendix E. Behavioral Health Measures
 

In developing the process and outcomes/impact measures described in Chapter Seven, we identified measures relevant to 

behavioral health settings. In Table E.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 

behavioral health organization or setting might wish to consider to help it assess how well it is doing in addressing identified 

disparities in outcomes. Table E.2 provides additional detail for each measure and summarizes the relevant items that comprise each 

measure. 

Table E.1. Behavioral Health Measures 

Measure(s) Description Area of Focus Source/ID Notes Reference 

Experience of Care 

and Health 

Outcomes (ECHO) 

Survey 

The Experience of Care and Health Outcomes 

(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: managed 

care organizations (MCOs) and managed 

behavioral healthcare organizations (MBHOs). 

Patient experience ECHO See Table E.2 for 

list of measures. 

ECHO Survey 

(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: 

National 

Committee of 

Quality Assurance 

[NCQA]) 

This is a disparitysensitive 

measure. 

NQF Quality 

Positioning 

System 

Measure 

Specifications 

(search: “2599”) 

97
 
Measure(s) Description Area of Focus Source/ID Notes Reference 

Initiation and 

engagement of 

alcohol and 

other drug 

dependence 

treatment 

Percentage of patients ages 13 years of age 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 Quality 

Positioning 

System 

Measure 

Specifications 

(search: “4”) 

(NQF, undated) 

National Voluntary 

Consensus 

Standards for 

Ambulatory 

Care—Measuring 

Healthcare 

Disparities 

(NQF, 2008) 

Antidepressant 

Medication 

Management 

(AMM) 

The percentage of patients ages 18 and older with 

a diagnosis of major depression who 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 Quality 

Positioning 

System 

Measure 

Specifications 

(search: “105”) 

(NQF, undated) 

National Voluntary 

Consensus 

Standards for 

Ambulatory 

Care—Measuring 

Healthcare 

Disparities 

(NQF, 2008) 

Thirty-day allcause 

unplanned 

readmission 

following 

psychiatric 

hospitalization 

in an inpatient 

psychiatric 

This facility-level measure estimates an all-cause, 

unplanned, 30-day risk-standardized readmission 

rate (RSRR) for adult Medicare fee-for-service 

(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: 

Centers for 

Medicare & 

Medicaid Services 

[CMS]) 

NQF Quality 

Positioning 

System 

Measure 

Specifications 

(search: “2860”) 

(NQF, undated) 

SAMHSA National 

98
 
 99
 

 

Measure(s) Description Area of Focus Source/ID Notes Reference 

facility (IPF) Behavioral Health 

Quality 

Framework 

Examples of 

Recommended 

Measures and 

Identified Gaps 

(SAMHSA, 2014b) 

Table E.2. Behavioral Health Measures: Additional Details 

Measures Items 

Experience of Care and Health 

Outcomes (ECHO) Survey 

(MEASURES BELOW: 5 

composite and 17 individual 

measures) 

The Experience of Care and Health Outcomes (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: managed care organizations (MCOs) and managed behavioral health care organizations 

(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 
100
 

Measures 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 

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 
 

 

 

 

 

Appendix F. Public Health Measures
 

In developing the process and outcomes/impact measures described in Chapter Seven, we identified measures relevant to public 

health settings. In Table F.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 

F.2 provides additional detail for each measure and summarizes the relevant items that comprise each measure. 

Table F.1. Public Health Measures 

Measure(s) Description Area of Focus Source/ID Notes Reference 

Developing a SelfAssessment Tool 

for Culturally and 

Linguistically 

Appropriate 

Services (CLAS) 

in Local Public 

Health Agencies 

(LPHAs) 

This self-assessment tool for local public health 

agencies (LPHAs) aims to offer sound measures of 

culturally and linguistically appropriate services 

(CLAS). The term LPHA is defined as a publicly 

funded entity (i.e., local health department, local 

board of health, or 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 

overlaps, 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. 

Culturally and 

linguistically 

appropriate 

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 

self-assessment 

tools, measures 

have yet to be 

tested/validated. 

See Table F.2 for 

list of measures. 

Developing a SelfAssessment Tool 

for Culturally and 

Linguistically 

Appropriate 

Services in Local 

Public Health 

Agencies – Final 

Report 

(COSMOS 

Corporation, 

2003) 

101
 
 102
 

Measure(s) Description Area of Focus Source/ID Notes Reference 

Consumer 

Assessment of 

Healthcare 

Providers and 

Systems (CAHPS) 

Clinician/Group 

Survey (CGCAHPS) 

Consumer Assessment of Healthcare Providers 

and Systems (CAHPS) Surveys ask consumers 

and patients to report on and evaluate their 

experiences with health care. The CAHPS 

Clinician/Group Survey (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 F.2 for 

list of measures. 

CAHPS 

Clinician/Group 

Survey 

(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 is collected via 

the CAHPS 5.0H adults survey for Medicare, 

Medicaid, and commercial populations. It is 

reported as two separate rates stratified by age: 

18–64 and 65 years of age and older. 

Health and wellbeing NQF #39 

(measure steward: 

National 

Committee of 

Quality Assurance 

[NCQA]) 

This is a disparitysensitive 

measure. 

NQF Quality 

Positioning 

System 

Measure 

Specifications 

(search: “39”) 

(NQF, undated) 

Healthcare 

Disparities and 

Cultural 

Competency 

Consensus 

Standards: 

DisparitiesSensitive Measure 

Assessment 

(NQF, 2012g) 

Asthma 

emergency 

department 

visits 

Percentage of patients with asthma who have 

greater than or equal to one visit 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 Quality 

Positioning 

System Measure 

Specifications 

(search: “1381”) 

(NQF, undated) 
103
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measure(s) Description Area of Focus Source/ID Notes Reference

Healthcare

Disparities and

Cultural 

Competency 

Consensus

Standards: 

DisparitiesSensitive Measure

Assessment

(NQF, 2012g)

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 wellbeingNQF #1515

(measure steward: 

NCQA)

This is a disparitysensitive

measure.

NQF Quality 

Positioning

System

Measure

Specifications 

(search: “1515”)

(NQF, undated)

Healthcare

Disparities and

Cultural 

Competency 

Consensus

Standards:

DisparitiesSensitive Measure

Assessment

(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: 

AMA-convened

Physician

Consortium for

Performance

Improvement)

NQF Quality 

Positioning

System

Measure

Specifications 

(search: “28”)

(NQF, undated)
 

 

 

 

Table F.2. Public Health Measures: Additional Details 

Measures	 Items 

Developing a Self-Assessment 

Tool for Culturally and 

Linguistically Appropriate 

Services (CLAS) in Local Public 

Health Agencies (LPHAs) 

(MEASURES BELOW) 

This self-assessment tool for local public health agencies (LPHAs) is aimed to offer sound measures of culturally and 

linguistically appropriate services. The term LPHA is defined as a publicly funded entity (i.e., local health department, local 

board of health, or 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 overlaps, 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. Please 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? 

Client services 

questionnaire: 

quality monitoring and 

improvement 

1.	 Does your agency have a formal plan for collecting information on the quality of culturally and linguistically appropriate 

services provided to clients? 

2.	 Which of the following activities are used to collect information on the quality of culturally and linguistically appropriate 

services? 

3.	 For what purpose(s) does your agency collect this information? 

4.	 Which of the following outcome data are collected in the quality improvement (QI) studies you conduct? 

5.	 In which of the following ways are data from various QI studies used? 

6.	 Does your agency conduct periodic assessments of community and/or clients’ needs? 

7.	 In which of the following ways does your state health department or local board of health support QI activities and 

needs assessments?
 

8.	 Does your agency have an internal working group or committee that coordinates, advises, or serves as a resource for 

planning and evaluation of services provided specifically to culturally and linguistically diverse groups? 

9.	 Are provider and client information for performance assessments and QI activities linked? 

104
 
Measures	 Items 

Client services 

questionnaire: 

management information 

systems (MIS) 

1.	 Does your agency’s client information database record race and ethnicity? 

2.	 Please report or estimate what percentage of your clients falls into the following racial groups. 

3.	 Please report or estimate what percentage of your clients falls into the following ethnic groups. 

4.	 Does your agency’s client information database record the primary language spoken by each client? 

5.	 Approximately what percentage of your clients speaks a primary language other than English? 

6.	 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 disenrollment)? 

Client services 

questionnaire: 

translation and interpretation 

services 

1.	 Which of the following types of written materials are available to your clients in one or more languages other than 

English? 

2.	 Which of the following activities are used to develop written materials in languages other than English? 

3.	 Which of the following practices generally apply to the translations of written materials provided by your agency to its 

clients? 

4.	 Which of the following entities provide review and/or approval of translated materials and products available to your 

clients? 

5.	 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? 

6.	 What methods are used by your agency to determine the need for translation of written materials into languages 

spoken by your clients? 

7.	 Which of the following sources are used to determine the languages spoken by the populations served by your 

agency? 

8.	 Which of the following methods are used to inform clients of the availability of translated documents and materials? 

9.	 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? 

10. Which of the following interpretation services are available to your clients? 

11. Which of the following characteristics apply to the language interpreters used by your agency? 

12. Which of the following entities review and/or approve staffing and operation of interpretation services available to your 

clients? 

13. 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? 

14. What methods are used by your agency to determine the need for interpretation services? 

15. 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? 

16. 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? 

17. Which of the following methods are used to inform clients of the availability of bilingual speakers and interpretation 

services in your agency? 

18. Is there a specific budget line for the allocation of funds to support bilingual speakers and interpretation services in 

your agency? 

19. For which of the following groups are translated materials and interpretation services generally made available by your 

agency? 

105
 
Measures	 Items 

Client services 

questionnaire: 

other related client services 

1.	 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)
 

2.	 Which of the following complementary or alternative healing practices are offered to your clients? (Mark all that apply) 

3.	 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) 

4.	 Which of the following characteristics pertain to written materials available to your clients? (Mark all that apply) 

5.	 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) 

6.	 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) 

Consumer Assessment of 

Healthcare Providers and 

Systems (CAHPS) 

Clinician/Group Survey (CGCAHPS) 

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surveys ask consumers and patients to report on 

and evaluate their experiences with health care. The CAHPS Clinician/Group Survey (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. 

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. 

106
 

 

 

 

 

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NIMH—See National Institute of Mental Health. 

NQF—See National Quality Forum. 

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119
 
 

 

 

 

 

 

 

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