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CORe Document Audit Scoring Sheet

The Cultural Competence Organisational Review (CORe) document audit scoring sheet is part of the Cultural Competence Organisational Review (CORe) tool

which was developed in partnership by Merri Community Health Services, the University of Melbourne and the Centre for Culture, Ethnicity and Health.

The document audit scoring sheet is designed to facilitate an audit of current organisational documents (including policies, procedures, plans and

assessment of tools). Using the CORe framework, documents are to be reviewed on the basis of their relevance to the cultural competence domains and

their indicators. Examples of how to complete the sheet are given below (in italics). Refer to the “Introduction to CORe-Scoring guidelines” for more

information.

Domain Cultural competence indicator Evidence and information provided Level of evidence for each domain Organization-wide policy, e.g. policy Planning directive, e.g. strategic plan Reporting directive, e.g. performance indicator, accountability measure

Score for each level of evidence 0=insufficient evidence 1=partly addressed 2=addressed completely

Organizational values

Lead

ers

hip

, in

vestm

ent

an

d

docum

enta

tio

n

Individuals at executive level have responsibility for implementing and monitoring cultural competence initiatives Teams or committees of mid-level or high-level staff are assigned responsibility for coordinating cultural competence activities. Funding is allocated to cultural competence.

E.g. A manager at exec level has responsibility

for developing a cultural competence plan

An organisational committee consisting of

managers and staff from different program areas

are responsible for cultural competence related

activities. This is a new committee

Currently there is no budget allocated

specifically for cultural competence activities,

however a business case for funding cultural

Policy: Comments Some policies in place express the organization’s commitment to cultural competence. Planning: Comments: A newly developed cultural

competence committee will

develop a framework for

cultural competence activities

2

Staff are aware of the cultural competence plan and implement it in their work. There are public materials that express the organization’s commitment to cultural competence.

competence activities will be developed.

There is no cultural competence plan however

the organisation’s plans and policies have a

general commitment to respecting cultural

diversity.

There are organisational brochures that have

pictures reflecting the diverse community and

statements supporting and respectiving cultural

diversity

and funding applications.

Reporting: Comments Reporting mechanisms will

be developed. There will be

an individual at executive

level responsible for

monitoring cultural

competence activities

Info

rmation/d

ata

rela

ted t

o

cultura

l com

pete

nce

Mechanisms are in place to collect and disseminate information on cultural competence, including relevant data sets and resources. The organization conducts regular self-assessments of its progress. Regular community needs assessments are conducted

Some data sets are used by the organization e.g. ABS data, This is not done on a regular basis. Focus groups are conducted occasionally in relation to specific services/programs. Client feedback surveys are available at reception.

3

Org

aniz

atio

nal

flexib

ility

Administration and service delivery adaptations are tailored to the population of the service area, including adaptations to improve access to care.

Focus groups are conducted occasionally in relation to specific services/programs. Client feedback surveys are available at reception.

4

Governance

Com

mun

ity invo

lvem

ent

at

board

and

advis

ory

levels

boa

rd a

nd a

dvis

ory

le

vels

Co

mm

unity in

volv

em

ent a

t b

oard

an

d a

dvis

ory

leve

ls

Boards and advisory committees are representative of groups served by the organization Community members are provided with financial and other necessary supports for their involvement in governing and advisory committees. Regular reports are provided to stakeholder’s on cultural competence issues and activities

Policy: Comments: Planning: Comments: Reporting: Comments

5

Board

deve

lop

me

nt Board members participate in

ongoing education on cultural competence.

Polic

y

Cultural competence is included in policies on: • personnel recruitment and retention • training and staff development • language access and communication • management of grievances and complaints • community and client input and participation

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Planning, monitoring and evaluation

Clie

nt, c

om

munity c

lient, c

om

mu

nity a

nd s

taff inpu

t

Culturally and linguistically diverse communities are represented on relevant planning and monitoring committees. Staff, clients and relevant communities have input into cultural competence plans. Staff, clients and relevant communities have input into the monitoring and evaluation of cultural competence activities. Staff and consumers actively participate in planning, monitoring and evaluation.

Policy: Comments: Planning: Comments Reporting: Comments

Pla

ns a

nd th

eir

imp

lem

enta

tion

Planning documents, including budget allocations, address cultural competence issues. A cultural competence plan is created and implemented.

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Colle

ction a

nd u

se o

f

info

rmation

Data collected from and about clients and target communities is used to inform planning. All areas of the organization (e.g. policy, programs, operations) collect and have access to relevant data. The implementation and results of cultural competence activities are monitored and evaluated as part of quality improvement processes.

Communication

Unders

tandin

g d

iffe

rent

com

mu

nity n

eeds a

nd

sty

les o

f clie

nt

po

pula

tion

There is a system to identify and record population and client language preferences, literacy levels and level of English proficiency. Staff receive training in cross-cultural communication.

Policy: Comments

8

Staff apply effective communication techniques with diverse groups.

Planning: Comments: Reporting: Comments:

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Cultura

lly a

ppro

pri

ate

ora

l com

munic

atio

n

Staff are trained in the appropriate use of qualified interpreters. Protocols are established for when and how to elicit sensitive information from clients. Clients can communicate in their preferred language/dialect at point of first contact and at all levels of interaction with the organization. Clients can understand translated material.

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Cultura

lly a

ppro

pri

ate

wri

tte

n

com

mu

nic

ation

writt

en c

om

mu

nic

ation

Printed, online and audiovisual materials are appropriate to the literacy of target populations. • Quality review mechanisms are established to check the integrity of translated materials. • Culturally appropriate ways to disseminate written materials are identified. • Clients understand written materials.

Staff Development

T

rain

ing

com

mitm

ent

Training in cultural competence is regarded as a core competency in quality improvement efforts. There is a training program for staff development in cultural competence.

Policy: Comments: Planning: Comments Reporting: Comments

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T

rain

ing c

on

tent

Cultural competence training needs are assessed. Community input is obtained regarding staff training. The quality of staff training is assessed. Staff demonstrate cultural competence in knowledge, skills, attitude and behaviour (both generally applicable and related to specific groups).

Sta

ff

perf

orm

ance

Cultural competence is incorporated into job descriptions. Staff performance evaluations are conducted in a culturally competent manner.

Organizational infrastructure

Fin

ance

an

d b

udg

ets

There is an overall budgetary allocation and investment in cultural competence activities, aligned with the organization’s strategic plan. Persons are designated to monitor the need for additional resources or funding.

. Policy: Comment: Planning: Comments: Reporting: Comments:

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Tech

nolo

gy

Appropriate technologies are used to facilitate communication between clients and service providers. Staff are trained to use the organization’s information system to collect, enter and use data related to cultural competence, in a consistent and standardised way.

Lin

ks a

nd p

artn

ers

hip

s

Formal and informal alliances are formed with community and other partners to address issues related to cultural competence. Internal coordination between departments facilitates the delivery of culturally competent care. There is evidence of appropriate use of and referral to partner agencies.

Is The

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Services and Interventions C

lient, fa

mily

and c

om

munity

inp

ut

There are policies and plans regarding client, family and community input. Workers obtain client, family and patient advocate input regarding care planning and treatment, as appropriate. Care and treatment plans are agreed upon by clients and families, and may be amended with client/family input as appropriate. Community input is obtained for community-level interventions.

Policy: Comment: Planning: Comment Reporting: Comment

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Scre

en

ing, a

ssessm

ent a

nd c

are

pla

nnin

g

Guidelines and tools are used to elicit cultural and demographic factors relevant to clients’ health and health behaviors. Data is routinely available on cultural and language needs, populations and clients served. Screening, assessment and care planning reflect cultural and ethnic considerations. Prevention, treatment and maintenance plans reflect factors related to cultural competence.

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Tre

atm

ent a

nd f

ollo

w u

p

Practice guidelines and treatment frameworks account for differences related to culture and traditional beliefs and practices, as appropriate. Health education is provided at client and population levels on issues that are related to the community. Treatment processes and outcomes related to culturally and linguistically diverse clients are regularly assessed as part of a quality improvement program. Outreach services are provided to target populations to facilitate access to care.

Partnerships and networks

Policy: Comments: Planning: Comments: Reporting Comments:

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