Volume TenNumber Ten

October 2008 Published Monthly

Earn CEU creditsee insert

Feature Focus:

Coordinating external requests for

information in the Compliance Office

page 38

Meet

Cathy Garrey, Compliance and Quality Assurance Manager, McHenry County Mental Health Board page 14

exploring the question: Does this really make a compliance program

“effective”?page 27

Connect with your Peers—Use HCCA’s Compliance & Ethics Social NetworkFind out how on page 9

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Editor’s note: Maria B. J. Chun is the Associate Chair, Administration and Finance in the Department of Surgery at John A. Burns School of Medicine at the University of Hawaii. Dr. Chun may be reached in Honolulu by telephone at 808/586-2925 or by e-mail at mariachu@hawaii.edu.

Due to the growing diversity of the US population, the need for cultur-ally competent health care has been

emphasized, and even required, by various oversight agencies and accrediting bodies.1 Although Title VI of the Civil Rights Act was passed in 1964, confusion over how to trans-late the law into actual practice has only been seriously addressed over the past decade.2 The Department of Health and Human Services has taken the lead by putting forth mandates, guidelines, and recommendations (referred to collectively as the National Standards for Culturally and Linguistically Appropriate Services or CLAS standards) as a means to formalize what it expects in terms of “cultural competency” in health care and how it can be implemented. The Centers for Medicare and Medicaid Services (CMS) has issued a CLAS implementation guide and a cultural compe-tency crosswalk that links the CLAS standards with the standards of the Joint Commission (formerly JCAHO), the National Committee for Quality Assurance (NCQA), and URAC (formerly Utilization Review Accreditation Commission).3,4 Included in these documents are numerous toolkits and resources providing further guidance.

The 14 CLAS standards are organized into three themes: n Culturally competent care (standards 1-3) n Language access services (standards 4-7)n Organizational supports for cultural com-

petence (standards 8-14)

The first two themes deal directly with the actual provision of health care, and the third theme addresses administrative and infrastructural issues related to providing culturally competent care.1,3 The standards are classified as mandates, guidelines, and recommendations.5 Mandates are defined as current federal requirements that must be followed by both individuals and entities, as specified, who receive federal funds. These mandates are tied to ensuring linguistically appropriate access to health care for those with limited English proficiency. The Office of Minority Health then deems the remaining standards as guidelines and recommenda-tions. Guidelines are activities that should be adopted. Recommendations are suggestions that a health care organization may want to consider implementing. Table 1 (on page 7) lists the 14 CLAS standards.

Particularly in the case of the four mandated standards, how can an organization assess compliance? Given that Standard 9 makes specific reference to auditing as a method to evaluate CLAS implementation, the U.S. Government Accountability Office’s (GAO) Government Auditing Standards (aka Yellow Book) provides a helpful risk assessment tool through its “elements of a finding” approach,

Cultural competency standards: Using the GAO Yellow Book

elementsBy Maria B. J. Chun, PhD

Affinity Group MeetingsHold your own

meeting in conjunction with HCCA’s 2009

Compliance Institute!Planning on attending the Compliance Institute? Need to hold a meeting of your own? Affinity group meetings are now available in conjunction with the Compliance Institute.

Not only do you get the benefit of holding your meeting along-side the most comprehensive compliance conference for compliance professionals, but you also receive complimentary meeting room space at the conference site, your choice of a complimentary continental breakfast or an am or pm break, and registration at the HCCA Member rate for your attendees.

Affinity Group Meetings may be held on one of the following days:

Saturday, April 25, 2009 Wednesday, April 29, 2009 (afternoon)Thursday, April 30, 2009

To apply, please visit www.compliance-institute.org (conference tab) and fill out the Affinity Group Meeting form. Please return the completed form to the HCCA office.

Questions? Contact Jennifer Jansen at 952.405.7922 or email her at jennifer.jansen@hcca-info.org

Health Care Compliance Association • 888-580-8373 • www.hcca-info.orgOctober 2008

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which ensures that the understanding of an issue/area of concern is complete.6 The ele-ments of a finding are comprised of Criteria, Condition, Cause, Effect, and Recommenda-tion (CCCER).

Definitions

Criteria - defines the what should be and include laws, regulations, contracts, grant agreements, standards, measures, expected performance, and so on.

Condition - describes what is or the current situation.

Cause - refers to the why or an explanation for the current situation, which may be due to such factors as lack of or poorly designed policies and procedures or incomplete or incorrect implementation.

Effect - describes what will happen or the impact and spells out the discrepancy between the criteria (what should be) versus the condition (what is).

Recommendation - refers to what will be done or what action(s) will be taken to correct the situation.

To provide an example, of how the CCCER approach may be applied to the CLAS stan-dards, we present the following hypothetical situation utilizing Standard 7:

You are the manager of one of seven outpatient clinics that are part of a large hospital. The Chief Operating Officer (COO) of the hospital has tasked all clinic managers with determining whether each of the clinics are meeting CLAS standards. The COO has provided you with verbal and written instructions on how to utilize CCCER and has asked that you start your assessment with Standard 7.

Criteria (what should be)Standard 7 (Mandate)Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

Condition (what is)After reviewing patient data, you determine that your patient population consists of a large number of recent immigrants from the Philippines and Korea. But, you notice that all patient-related materials (e.g., consent forms, conflict and grievance procedures, informational/educational brochures) are available only in English.

Cause (why this happened)You and your staff were unaware that these materials were mandated by the federal gov-ernment. The hospital administration had not provided any guidance in this area. Because some of your staff are bilingual and have been able to converse in the native languages of the patients, there was an assumption that this was sufficient.

Effect (why this matters)Not only is the clinic out of compliance with a federal mandate, more importantly, it has not been culturally competent or sensitive to its patients’ needs. A patient may have consented to a procedure or a payment plan without fully understanding what was actually involved. This puts the clinic under potential legal and/or fiscal liability.

Recommendation (what will be done)You immediately report your finding to the hospital COO and recommend that you and your staff be provided with cultural competency training with a focus on CLAS standards. You also request a more detailed needs assessment to determine exactly what

patient-related materials and signage are needed, and in what languages, to properly assist your patient population.

The above scenario simplifies the complexities faced when trying to deal with cultural com-petency issues. However, utilizing CCCER is a good starting point and serves as a means to identify potential risk areas without over-whelming those tasked with ensuring cultural competency compliance. This should not replace a comprehensive organizational assess-ment, but once again, can serve as a basis for such an endeavor. Cultural competency will continue to grow in significance. What the federal government now deems as guidelines and suggestions, may soon become mandates.

If you have already, or are planning to, assess cultural competency in your organization, please contact me (mariachu@hawaii.edu) and let me know what methods you have used or are planning to use. n

1 Brannigan, M.C. 2008. Connecting the dots in cultural competency: Institutional strategies and conceptual caveats. Cambridge Quarterly of Healthcare Ethics, 17: 173-184.

2 Beamon C, Devisetty V, Forcina Hill JM, et al: A Guide to Incorporat-ing Cultural Competency into Medical Education and Training. December 2005, National Health Law Program.

3 http://www.qsource.org/uqiosc/CLASGuide.pdf. Accessed 7/1/08.4 http://www.qsource.org/uqiosc/CLAS_Standards_Crosswalk_v3.pdf.

Accessed 7/1/08.5 http://www.omhrc.gov/templates/browse.aspx?1v1=2&1v1ID=15.

Accessed 7/2/08.6 United States Government Accountability Office. July 2007. Govern-

ment Auditing Standards, July 2007 Revision. Also available online at: http://www.gao.gov/govaud/ybk01.htm.

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Table 1: 14 CLAS Standards

U.S. Department of Health and Human

Services, Office of Minority Health

Standard 1 (Guideline)Health care organizations should ensure that patients/consumers receive from all staff member’s effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

Standard 2 (Guideline)Health care organizations should imple-ment strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are repre-sentative of the demographic characteristics of the service area.

Standard 3 (Guideline)Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

Standard 4 (Mandate)Health care organizations must offer and provide language assistance services, includ-ing bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.

Standard 5 (Mandate)Health care organizations must provide

to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

Standard 6 (Mandate)Health care organizations must assure the competence of language assistance provided to limited English proficient patients/con-sumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).

Standard 7 (Mandate)Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

Standard 8 (Guideline)Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.

Standard 9 (Guideline)Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evalua-tions.

Standard 10 (Guideline)Health care organizations should ensure that data on the individual patient’s/

consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated.

Standard 11 (Guideline)Health care organizations should maintain a current demographic, cultural, and epide-miological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

Standard 12 (Guideline)Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implement-ing CLAS-related activities.

Standard 13 (Guideline)Health care organizations should ensure that conflict and grievance resolution pro-cesses are culturally and linguistically sensi-tive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.

Standard 14 (Suggestion)Health care organizations are encouraged to regularly make available to the public information about the progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information.