Organizational journeys to CLAS, Part I: Readiness to engage

Rationale:
According to the 2000 U.S. Census, one in four Americans list their race as other than white and over 47 million people – more than 18 percent of the U.S. population, speak a language other than English at home. Within Sutter Health’s primary service area, 32.8 percent primarily speak a language other than English and an additional 15.8 percent of the service population is categorized as Limited English Proficient (LEP). Sutter Health understands that in order to address health care disparities and provide quality care for all patients, a culturally competent environment is required to empower patients and staff to effectively interact cross-culturally. It was also understood an environment that requires equitable accountability for cultural competence across work functions throughout the organizations would leverage existing resources and support systems change. 

Objective:
Planning session objectives revealed the need for a strategic and multi-phased methodology to guide Sutter Health through the process of implementing organizational change. To initiate development of the desired environment, first a clear assessment of Sutter Health's current strengths, opportunities for growth and systematic gaps needed to be identified.  As planning progressed, a concurrent organizational cultural competence assessment was implemented to provide a “snapshot” of Sutter Health's existing capacity to support a culturally competent care and work environment.  To provide structure to the assessment, Domains derived from the Organizational Cultural Competence Assessment Profile prepared by Health Resources and Services Administration (HRSA) and the Office of Minority Health's (OMH) Culturally and Linguistically Appropriate Services (CLAS)standards were utilized.  The Domains provide the underlying construct of cultural competence within a healthcare organization, and the critical areas in which cultural competence should be evident or manifest in an organization.     

     The (HRSA) Domains (http://www.hrsa.gov/culturalcompetence/indicators/default.htm)

• Organizational values
  
• Governance
  
• Planning/monitoring
  
• Communication 
  
• Staff development
  
• Organizational infrastructure
  
• Services/interactions
  

Methods:
The methodology for the assessment developed by Paul T. Doyle Associates, LLC provided framework for the collection of data, analysis, scoring and reporting. An assessment team then quantified the Sutter Health’s system's capacity to support cultural competence, based on a five-point scale.  Based on these data collected, the team scored Sutter Health's ability to reflect the structural and output indicators of the Organizational Profile. The assessment results demonstrated that efforts to meet diverse patient needs were often fragmented, not connected to quality improvement efforts and lacked a framework to measure impact of implemented initiatives. The patient data collection process did not support outcomes stratified by race, ethnicity or language.  There was a low level of awareness and knowledge among leadership regarding how to utilize organizational cultural competence to resolve these issues and support organizational goals. 
Based on findings and insights, the leadership at Sutter Health knew that to move their large, complex health care system along the journey of organizational cultural competence, they had to established an expectation of equitable accountability throughout their system when asking and attempting to answer fundamental questions related to organizational cultural competence: 

• Where is the organization currently?
  
• Where does the organization want to go?
  
• How will the organization get there?
  

Work from the assessment and ongoing planning were then framed in a strategic blueprint that clustered findings/results and plotted key strategies on an actionable timeline for achievement.  The blueprinting process was collaborative to ensure ownership and alignment of key leaders and staff. Communication of messages was designed to educate and advocate for change. Strategic alignment with organizational dashboard metrics further supported implementation of infusing cultural competence criteria within protocols, processes, procedures and system priority areas.

Where is the organization currently?
Sutter Health leadership communicated their commitment to enhance its capacity to demonstrate the highest levels of quality and service for all of the diverse communities it serves based on assessment results. Sutter Health retained the services of Paul T. Doyle & Associates, LLC, to guide their work forward by providing the necessary knowledge and resources to implement blue print action steps and develop a framework for organizational cultural competence that supports their efforts to:

• Comply with state and federal guidelines (CLAS) related to caring for Limited English Proficiency (LEP) patients
  
• Strategically link cultural competence efforts to dashboard indicators to support organizational goals and transformation priority areas
  
• Standardized collection of patient demographics to support quality care measurement
  
• Support a diverse and inclusive work environment for over 50,000 staff members
  

Where does the Organization Want to Go?
Sutter Health will utilize cultural competence as a key strategy to fulfill their mission and support organizational goals related to quality, service, community benefit, people, finance and strategic growth. Current cultural competence objectives are focused on developing a framework for all 26 Sutter Health’s hospitals and 9 medical foundations to infuse cultural competence criteria within key organizational work areas that include:

• Quality Integration
  
• Language Access
  
• Strategy and Business Development
  
• Communication and Marketing
  
• Community Benefit
  
• Clinical Education
  
• Organizational Development and Training
  
• Physician Medical Network
  
• Electronic Health Record (EHR)
  
• Human Resources (Staff Recruiters)
  
• Patient Scheduling and Registration
  
• Board Governance
  

How will the Organization Get There?
Sutter Health determined that organizational cultural competence objectives must focus on “results oriented strategies” rather than high profile activities. These strategies must infuse cultural competence into existing organizational activities rather than approaching it as a separate or “another initiative." Knowledge of the organizational priorities areas is critical to aligning cultural competence efforts and then demonstrating the “value” of organizational cultural competence to meeting goals within the priority areas. Sutter Health continues to demonstrate the value of organizational cultural competence to its priority areas and will focus on this strategy to continue moving the organization forward.

• Quality – consistent and accurate data collection to address health and health care disparities.
• Affordability – utilize a community health improvement approach to support the utilization of care services in the most appropriate and cost effective manner
• Process Transformation and EHR – Consistent and accurate documentation of patient demographics by race, ethnicity, sex and language etc.
• Physician Network – enhance language assistance resources to facilitate communication between patient and providers.
• Strategic Investment – build intentional relationships of trust with diverse communities to establish Sutter Health as their provider of choice.
  

The intent of Sutter Health to establish a framework that supports culturally competent work and care environment based on equitable accountability is progressing. the organization supports ongoing education, advocacy and evaluation as critical success factors to sustaining efforts and achieving effective systems change in the future.

Success to Date:
Facilitating systems change to enhance organizational cultural competence can often feel as daunting as trying to “move a mountain.” However, Sutter Health’s achievements demonstrate “progressive improvement, not postponed perfection” (Doyle). Systems change examples include:

• Top level leadership support = CEO serves as Executive Sponsor
  
• Dedicated cultural competence resources and budget
  
• Standardized systemwide approach to data collection 
  
• Utilization of community benefit initiatives to educate executive leadership and enhance their community engagement with culturally diverse groups
  
• Revised staff survey to obtain staff perspective regarding organizational cultural competence efforts
  
• Cultural Competence established as a standard learning component at annual systemwide management symposium
  
• Chartered Cultural Competence Advisory Councils established
  
• Dedicated intranet Web site to support awareness and education
  
• Developed E-Learning curriculum based on 3 levels of core competencies
  
• Recruitment and Retention plan to increase underrepresented minority(URM) staff on all levels
  
• Governance (Board) Diversity Policy
  
• Utilize process redesign teams to ensure cultural competence criteria is infused within organizational transformation initiatives