Moving Towards Culturally
Competent Health Systems:
Organizational and Market Factors
Robert Weech-Maldonado, Ph.D.,
Department of Health Services Research,
Management & Policy
1
Collaborators

University of Florida




UCLA


Ron D. Hays, Ph.D.
RAND


Allyson Hall, Ph.D.
Cameron Schiller, MS
Jianyi Zhang, Ph.D.
Marc N. Elliott, Ph.D.
Penn State

Janice Dreachslin, Ph.D.
2
Acknowledgement

Project funded by the Commonwealth Fund

Project Officer: Dr. Anne Beal
3
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?
4
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
5
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)
6
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)
7
Cultural Competency Assessment Tool
for Hospitals (CCATH)



Project funded by DHHS OMH (WeechMaldonado, Hays, Brown, et al., 2006)
Based on CLAS standards
Instrument subjected to extensive qualitative
testing, including pilot testing, focus group
and cognitive interview testing
8
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)
9
Conceptual Framework
Structure of Care
Hospital’s
Adherence to
CLAS
Process of care
Racial/Ethnic
Minorities
Assessment of
Care
Outcomes
Racial/ethnic
Minorities
Satisfaction with
Care
Organizational and
Market
Characteristics
10
Factors Hypothesized to be Associated
with Greater CLAS adherence
Organizational 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 nonEnglish speakers

Located in metropolitan areas

Located in wealthier markets
11
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 nonrespondent 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%)
12
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)
13
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
14
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
15
CLAS Domains

HR practices (mean= 67)



Interpreter services policies (mean= 64)


Formal mentoring program
Flexible benefits such as domestic partner benefits,
family illness, death, and personal leave policies that
accommodate alternative definitions of family
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
16
CLAS Domains

Diversity training (mean= 53)


Quality of interpreter services (mean= 52)


Does this hospital have a formal and ongoing training
program on cultural and language diversity?
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
17
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)
18
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?
19
Independent Variables
Organizational Factors
 Diversity leadership
 Teaching hospital
 System membership
 Ownership (for-profit, notfor-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
20
Analysis
Adherence to CLAS standards=
f (organizational and market factors)
 Diversity leadership = f (organizational and
market factors)
 Ordinary least squares regression

21
Organizational Factors and Adherence to
CLAS Standards and Diversity Leadership
Adherence to
CLAS
Standards
Independent Variable
b
Diversity Leadership
0.436
<.0001
Teaching Hospital
0.144
System Hospital
Diversity
Leadership
b
P
0.163
0.129
0.250
-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
P
22
Organizational Factors and Adherence to
CLAS Standards and Leadership
Adherence to
CLAS Standards
Diversity
Leadership
Independent Variable
b
P
b
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
-0.018
0.828
0.034
0.715
Total Margin
23
Market Factors and Adherence to CLAS
Standards and Leadership
Adherence to
Cultural
Competency
Guidelines
Diversity
Leadership
Independent Variable
b
P
b
Herfindahl Index (HSA)
0.010
0.917
-0.319
0.003
-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
% Racial/Ethnic Minorities in
the Hospital's County
P
24
Organizational and Market Factors and Adherence to
CLAS Domains (Standardized Betas)
Domain
Diversity
Leadership
% Non-White
Patients
Not-ForProfit
Hospital
Government
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
System
Hospital
-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
Racial/Ethnic Assessments
and QI
0.29678
0.23725
0.27907
25
Organizational and Market Factors and Adherence to
CLAS Domains (Standardized Betas)
Teaching
Hospital
Cultural Competency Practices
Metropolitan
Hospital
% Medicaid
Patient
Days
% Managed
Care Patient
Days
Total
Margin
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
Racial/Ethnic Assessments and
Quality Improvement
-0.27319
26
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
27
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
28
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, nonmetro area data collection and service planning
on service area
System greater use of racial/ethnic assessments
and QI
29
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
30
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
31
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
32
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
33
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
34
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