Moving Towards Culturally Competent Health Systems: Organizational and Market Factors

Moving Towards Culturally Competent Health Systems: Organizational and Market Factors Robert Weech-Maldonado, Ph.D., Department of Health Services Research, Management & Policy

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.

Acknowledgement • Project funded by the Commonwealth Fund • Project Officer: Dr. Anne Beal

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?

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

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)

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)

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

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)

Conceptual Framework Structure of CareProcess of careOutcomes Racial/ethnic Minorities Satisfaction with Care • Hospital’s Adherence to CLAS • Racial/Ethnic Minorities Assessment of Care Organizational and Market Characteristics

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 non-English speakers Located in metropolitan areas Located in wealthier markets Factors Hypothesized to be Associated with Greater CLAS adherence

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%)

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)

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

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

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

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

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)

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?

Organizational 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 Independent Variables

Analysis • Adherence to CLAS standards= f (organizational and market factors) • Diversity leadership = f (organizational and market factors) • Ordinary least squares regression

Organizational Factors and Adherence to CLAS Standards and Diversity Leadership

Organizational Factors and Adherence to CLAS Standards and Leadership

Market Factors and Adherence to CLAS Standards and Leadership

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

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

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

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

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

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

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

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

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

Moving Towards Culturally Competent Health Systems: Organizational and Market Factors