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Moving Towards Culturally Competent Health Systems: Organizational and Market Factors

Robert Weech-Maldonado, Ph.D.,Department of Health Services Research, Management & Policy

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Collaborators University of Florida

Allyson Hall, Ph.D. Cameron Schiller, MS Jianyi Zhang, Ph.D.

UCLA Ron D. Hays, Ph.D.

RAND Marc N. Elliott, Ph.D.

Penn State Janice Dreachslin, Ph.D.

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Acknowledgement Project funded by the Commonwealth Fund

Project Officer: Dr. Anne Beal

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Research Question What is the relationship between

organizational and market factors and hospital cultural competency practices?

What is the relationship between organizational and market factors and hospital diversity leadership?

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Cultural Competency and Racial/Ethnic Disparities in Care Previous studies have shown racial/ethnic

differences in hospital treatment (Harris et al. 1997; Petersen et al., 2002) and patient experiences with inpatient care (Hicks et al. 2005; La Veist et al., 2000; Rogut et al., 1996)

Cultural competence “Ongoing commitment or institutionalization of

appropriate practices and policies for diverse populations” (Brach and Fraser, 2000:183)

Hospitals may play an important role in reducing disparities in care by becoming culturally competent organizations

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CLAS and Cultural Competency The national standards for culturally and

linguistically appropriate services (CLAS) in health care DHHS Office of Minority Health (2001) Provide guidelines on policies and practices aimed at

developing culturally appropriate systems of care CLAS standards

Culturally Competent Care (Standards 1-3) Language Access Services (Standards 4-7) Organizational Supports for Cultural Competence

(Standards 8-14)

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Organizational Assessments of Cultural Competency Organizational assessments provide a useful tool to

evaluate the structures (policies, programs) and processes (practices, culture) for cultural competency

Few hospitals have implemented cultural competency/diversity management practices even when they consider it an important organizational issue (Weech-Maldonado et al., 2002)

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Cultural Competency Assessment Tool for Hospitals (CCATH) Project funded by DHHS OMH (Weech-

Maldonado, Hays, Brown, et al., 2006) Based on CLAS standards Instrument subjected to extensive qualitative

testing, including pilot testing, focus group and cognitive interview testing

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Conceptual Framework Structure, Process, and Outcomes Framework

of Quality Assessment (Donabedian, 1988) Resource Dependence Theory (Pfeffer and

Salancik, 1978) Institutional Theory (Myer and Rowan, 1977)

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Conceptual FrameworkStructure of Care Process of care Outcomes

Organizational and Market Characteristics

Racial/Ethnic Minorities Assessment of Care

Racial/ethnic Minorities Satisfaction with Care

Hospital’s Adherence to CLAS

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Factors Hypothesized to be Associated with Greater CLAS adherenceOrganizational Factors Diversity leadership Teaching hospital System membership Not-for-profit hospitals Public hospitals Greater % of racial/ethnic

minority inpatient population Larger hospitals Lower % of Medicaid patients Lower % managed care patients Higher financial performance

Market Factors More competitive markets Higher proportion of

racial/ethnic minorities Higher proportion of non-

English speakers Located in metropolitan areas Located in wealthier markets

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Data

CCATH Survey Mail survey October 2006- May 2007 Sampling frame: All medical and surgical hospitals in California

as listed in the CA Hospital Association Directory (364 hospitals) Total Design Method (Dillman, 1978)

Response rate: 35% No significant differences between respondent and non-respondent

hospitals Except respondents less likely to be part of a system (49% vs. 64%) and less likely

to be in a metro area (76% vs. 87%)

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Data California Office of Statewide Health

Planning & Development’s (OSHPD) Hospital Inpatient Discharges (HID) Financial Reports

American Hospital Association (AHA) Annual Survey

Area Resource File (ARF)

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Dependent Variables Adherence to CLAS standards (1st research

question) Scores (1-100 possible range) for 10 domains

Factor analysis (Varimax rotation) Cronbach alphas > .70

Average score for 10 domains

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CLAS Domains Cultural competency practices (mean= 81)

Accommodate the ethnic/cultural dietary preferences of in-patients?

Tailor patient education materials for different cultural and language groups?

Access to interpreter services (mean= 69) Are interpreter services available for in-patients in the

following languages? IF YES: Which services are available? (Mark all that apply) Bilingual staff as interpreters Face-to-face professional interpreters Face-to-face volunteer interpreters Telephone interpreter services

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CLAS Domains HR practices (mean= 67)

Formal mentoring program Flexible benefits such as domestic partner benefits,

family illness, death, and personal leave policies that accommodate alternative definitions of family

Interpreter services policies (mean= 64) Does this hospital have a written policy and procedures

about the use of... Family or friends as interpreters? Data collection on service area (mean= 55)

Does this hospital collect or receive any of the following data on the population residing in the service area? Health risk profiles Income levels

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CLAS Domains Diversity training (mean= 53)

Does this hospital have a formal and ongoing training program on cultural and language diversity?

Quality of interpreter services (mean= 52) Does the hospital require an assessment of...

Interpreter accuracy and completeness? Translation of written materials (mean= 51)

What types of written materials does this hospital routinely provide to in-patients in languages other than English? IF YES: In what languages are written materials translated? (Mark all that apply) Discharge planning instructions Medication instructions

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CLAS Domains Community representation (mean= 39)

Are community representatives routinely involved in the... Planning and design of in-patient services for culturally diverse populations?

Racial/ethnic assessments and QI (mean= 33) Are the following assessments conducted at least

once each year? IF YES: Are results used in quality improvement? Racial/ethnic differences in in-patient service use Racial/ethnic differences in in-patient assessments of

care (satisfaction)

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Dependent Variables

Diversity leadership (2nd research question) Composite score (possible range 0-100) of six items

(mean=34). Cronbach alpha= 0.80 Does this hospital's statement of strategic goals include...

Specific language about recruitment of a culturally diverse work force?

Specific language about retention of a culturally diverse work force?

Specific language about the provision of culturally appropriate patient services?

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

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

Does this hospital report information to the community at least once per year about its performance in meeting the cultural and language needs of the service area?

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Independent VariablesOrganizational Factors Diversity leadership Teaching hospital System membership Ownership (for-profit, not-

for-profit, government) Size (small, medium, large) % Minority patients % Medicaid patients % Managed care Financial performance

(total margin)

Market Factors Competition (Herfindahl

Index) % of minorities in service

area % of non-English speakers

in service area Metropolitan area Per capita income

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Analysis Adherence to CLAS standards=

f (organizational and market factors) Diversity leadership = f (organizational and

market factors) Ordinary least squares regression

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Organizational Factors and Adherence to CLAS Standards and Diversity Leadership

Adherence to CLAS

StandardsDiversity Leadership

Independent Variable P P

Diversity Leadership 0.436 <.0001

Teaching Hospital 0.144 0.163 0.129 0.250

System Hospital -0.011 0.900 0.161 0.091

Government Hospital 0.122 0.318 0.121 0.367

Not-For-Profit Hospital 0.298 0.013 0.357 0.005

Medium size Hospital 0.049 0.658 0.204 0.093

Large Hospital 0.025 0.843 0.201 0.145

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Organizational Factors and Adherence to CLAS Standards and Leadership

Adherence to CLAS Standards

Diversity Leadership

Independent Variable P P

% Non-White Patients 0.304 0.006 0.243 0.037

% Medicaid Patient Days -0.026 0.779 0.012 0.907

% Managed Care Patient Days 0.102 0.302 0.052 0.634

Total Margin -0.018 0.828 0.034 0.715

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Market Factors and Adherence to CLAS Standards and Leadership

Adherence to Cultural

Competency Guidelines

Diversity Leadership

Independent Variable P P

Herfindahl Index (HSA) 0.010 0.917 -0.319 0.003

% Racial/Ethnic Minorities in the Hospital's County -0.391 0.110 -0.065 0.809

% Non-English Speakers in the Hospital's County 0.292 0.206 -0.021 0.933

Metropolitan County 0.013 0.901 -0.247 0.033

Per Capita Income (in thousands of dollars) 0.029 0.730 0.227 0.012

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Organizational and Market Factors and Adherence to CLAS Domains (Standardized Betas)

Domain Diversity Leadership

% Non-White Patients

Not-For-Profit Hospital

Government Hospital

System Hospital

Cultural Competency Practices

0.30967 0.25778 0.3364 0.26855

Human Resources Practices 0.27523

Diversity Training 0.37308

Access to Interpreter Services

-0.18778

Quality of Interpreter Services

0.27141

Interpreter Services Policies 0.25888

Translation of Written Materials

0.30276 0.37147

Data Collection on Service Area

0.23244 0.2914 0.23725

Racial/Ethnic Assessments and QI

0.29678 0.27907

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Organizational and Market Factors and Adherence to CLAS Domains (Standardized Betas)

Teaching Hospital

Metropolitan Hospital

% Medicaid Patient Days

% Managed Care Patient Days

Total Margin

Cultural Competency Practices 0.25153

Human Resources Practices -0.25576

Diversity Training

Access to Interpreter Services 0.20013

Quality of Interpreter Services

Interpreter Services Policies 0.26147

Translation of Written Materials

Data Collection on Service Area -0.27319

Racial/Ethnic Assessments and Quality Improvement

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Results Diversity leadership is the single most

important factor in predicting adherence to the CLAS standards

Being a not-for-profit hospital and having a more diverse inpatient population are also important predictors of cultural competency activities

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Results

The relationship of organizational and market factors to CLAS adherence varies by CLAS domains Leadership important predictor across all domains

except access to interpreter services Not-for-profit, government, system, teaching,

more diverse inpatient greater adherence to cultural competency guidelines

Higher % of Medicaid lower use of HR practices

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Results Higher profit margin and non-system greater

availability of interpreter services Higher % of managed care quality interpreter

services Greater % of diverse patients translation

services Greater % of diverse patients, not-for-profit, non-

metro area data collection and service planning on service area

System greater use of racial/ethnic assessments and QI

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Results Hospitals that are not-for-profit, medium size,

system members, have a larger diverse inpatient population, and are located in more competitive, non-metro, and wealthier markets have higher scores for diversity leadership

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Conclusions Hospital leadership and mission matter in

moving towards culturally competent health systems

Results suggest that hospitals adapt to the needs of its more diverse inpatient population by implementing cultural competency activities

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Conclusions Organizational factors such as system

membership, teaching hospital, size, managed care, and financial performance do not have a consistent relationship with CLAS adherence

Market factors such as hospital competition, population demographics and language, metropolitan area, and income do not have a consistent relationship with CLAS adherence

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Conclusions However, some of these organizational and

market factors may have an indirect impact on CLAS adherence through their relationship with diversity leadership. For example, being part of a system, medium

size, and competition do matter when it comes to greater diversity leadership. And diversity leadership is strongly related to adherence to the CLAS standards

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Policy/Research Implications Further research is needed on the business case for

cultural competency to raise the awareness of hospital CEOs and for-profit hospitals on the importance of cultural competency

Racial/ethnic minorities receiving care in hospitals with a less diverse inpatient population may have greater barriers to health care

Further research is needed to examine the implications of hospital’s adherence to the CLAS standards for patient experiences with inpatient care and outcomes of care