Community Support

Notes from a Roundtable on Conceptualizing and Measuring Cultural Competence

Appendix C : Issues Pertinent to the Selection of Cultural Competence Measures in Performance Measurement Systems

Mildred Vera, Ph.D.
Center for Evaluation and Sociomedical Research
School of Public Health
University of Puerto Rico

December 1998

Interest in performance measurement of the behavioral managed care delivery system has increased considerably. The expansion of managed care organizations for providing state funded behavioral health care has contributed to the need to identify if purchased services are delivered and the quality of care provided. A major goal of managed care practices is the reduction of health costs (Beaudin, 1998). To achieve this goal treatment strategies have been impacted by eliminating unnecessary treatments and procedures. Service providers are held accountable for treatment decisions. Demonstration of need for services has been identified as critical for determining access to care (Abe Kin and Takeuchi, 1996).

Ethnic minorities although an increasingly growing segment of the population report a lower use of mental health services in comparison with non-minorities (Hu et al., 1991). An increasing concern is that cost containment strategies under managed care systems negatively impact access to mental health care for minority populations. To increase access and quality care to underserved culturally diverse populations increased attention has been focused on the culture-related aspects of care. The importance that managed care environments develop a system of care that addresses ethnic and cultural factors has been widely acknowledged (Lavizzo-Mourey and Mackenzie, 1996; Dana, 1998).

Significant efforts in the health community have been geared towards the identification of relevant elements for the implementation of culturally competent systems of care. Most recently, joint work of four national racial/ethnic panels formulated a set of viable performance indicators aimed at improving the ability of managed care organizations to meet cultural competence standards that translate into measures of accountability. Particular emphasis is placed on the relevance of viewing mental health service consumers within the context of their cultural group recognizing that people develop different approaches in response to their life circumstances. The need for new approaches in the delivery of mental health services to address cultural variations among consumers from diverse ethnic populations is recognized.

The document Cultural Competence Standards in Managed Care Mental Health Services for Four Underserved/Underrepresented Racial/Ethnic Groups (1998) presented by the Consensus Panel members, specifies core cultural competence standards applicable to diverse ethnic/racial populations. The cultural competence standards developed address system, clinical and provider aspects of care. The expected outcome of the effective implementation and use of cultural competence standards is that managed care systems achieve progress in the development of a culturally competent work force and increase high-quality care for culturally diverse populations. For each standard relevant performance indicators and outcomes are also specified for use in measuring adherence.

Table 1 lists system, clinical, and provider areas for which cultural competence standards were identified. Implementation guidelines, performance indicators and outcomes are recommended for each standard. Table 2 presents, as an example, recommended performance indicators and outcomes for the standard on access and service authorization.

The effective implementation of cultural competence standards present significant challenges. As evidenced in the Cultural Competence Standards in Managed Care Mental Health Services (CCSMC) report (Tables 1 and 2 present an outline and example), the evaluation of cultural competence of health care delivery systems involves multiple aspects of care that address system, clinical, and provider issues.

The first set of standards and performance indicators addressed in the CCSMC document focuses on the health plan overall system, with particular emphasis on the cultural competence of the organization and managed practices (see Table 1). A basic premise is that the commitment of the organization to culturally competent care as reflected in its philosophy, mission, strategic planning, and organizational analysis sets the tone for the delivery of care. The organization of a health care system holds a major role in responding to the culture-driven needs of patients.

Providers acceptance of clinical standards is a major obstacle for performance based systems. Lack of time, poor understanding of appropriateness of intervention, uncertainty of measurement procedures are stated as reasons for provider failure to adopt standards. The socialization process of the health care provider is also identified as having a significant influence on the therapeutic interventions with culturally different patients (Jones et al., 1998). The document CCSMC emphasizes the need to address providers' knowledge, understanding, skills, and attitudes to ensure cultural competence among clinical staff.

The identification of appropriate measures of cultural competency that address diverse elements involved in the health care process (organizational, clinical and provider) is essential. The CCSMC document provides recommendations of performance indicators relevant for each standard. These indicators should provide the basis for guiding the identification of relevant measures.

A review of various measures of cultural competence revealed that while initial instruments focused mostly on the measurement of knowledge, attitudes and skills, most recent assessments respond to a more comprehensive perspective addressing both provider and organizational elements. The instrument Self-Assessment of Cultural Competence, from the National Public Health and Hospital Institute (1997) addresses several cultural competence standards included in the CCSMC document. The areas assessed are the following:

Ethnic/Cultural Characteristics of the Staff and Organization - Board, Staff & Patient/Community Profiles; Diversity Training; Database Systems & Data Development; Human resource Programs; and Union Presence.
Institutional Approaches to Accommodating Patient Needs and Attributes - Organizational Adaptation to Diversity, Managed Care & Quality Issues.
Institutional Links to the Communities Served by the Healthcare Organization.
Language & Communication Needs of Ethnic/Cultural Patient & Staff - Service Provision, Communication Issues, Patient Issues.

The Cultural Competence Self-Assessment Tool (Missouri Department of Mental Health, 1998) is a recent adaptation of a previous measure developed by James Mason. The content areas include: Knowledge of Diverse Communities, Personal Involvement/Awareness, Resources and Linkages, Staffing, Organizational Policies and Procedures, Reaching Out to Communities, and Staff-Client Interactions. Both measures strongly contribute to provide relevant information for the assessment of performance indicators included in the CCSMC document.

Information for the measurement of performance indicators can also be obtained from other sources: administrative data (enrollment/encounter data, claims files); program and medical records; and consumer self reports. Several factors must be considered when examining data sources for the selection of performance measures. The quality of the performance measure is highly dependent on the quality of the data set from which it is derived. Information from existing databases and records may be incomplete, inaccurate or misleading. Recruitment requirements and training of data collectors are identified as crucial elements to achieve high quality data. An established quality control program should guide data collection efforts; particular attention on ongoing editing and reviews of accuracy of data is essential.

The volume and complexity of data collection will also have a strong impact on the selection of performance measures. Computerized record keeping and integrated information systems facilitate the use of complex and large data sets for the selection of performance measures. Other desirable properties of performance measures are that they must be reliable and valid for their intended purpose providing similar results in comparable situations. Data collection procedures need to be clearly specified since decisions made have implications for the accuracy and credibility of the data.

Table 1. Overall system, clinical and provider areas for which cultural competence standards were developed

A. Overall System Standards
Cultural Competence Planning
Governance
Benefit Design
Prevention, Education, and Outreach
Quality Monitoring and Improvement
Decision Support and Management Information Systems
Human Resource Development
B. Clinical Standards
Access and Service Authorization
Triage and Assessment
Care Planning
Plan of Treatment
Treatment Services
Discharge Planning
Case Management
Communication Styles and Cross-cultural Linguistic and Communication Support
Self Help
C. Provider Competencies
Knowledge, Understanding, Skills, and Attitudes

Table 2. Sample standard, indicators and outcomes

Access and Service Authorization

Standard

Service shall be provided irrespective of immigration status, insurance coverage, and language. Access to services shall be individually- and family-oriented (including client-defined family) in the context of racial/ethnic cultural values. Access criteria for different levels of care shall include health/medical, behavior, and functioning in addition to diagnosis. Criteria shall be multi-dimensional in six domains: psychiatric, medical, spiritual, social functioning, behavior, and community support.

Recommended Performance Indicators

Procedures for access in place with specific provisions for consumers from the four groups.
Time from point of first contact through service provision for all levels of care are tracked by age, gender, ethnicity (i.e., particular subgroup and mixed origins), primary language, and level of functioning.
Rate and timelines of response to telephone calls by consumers from the four groups.

Recommended Outcomes

Tracking of authorization decisions including denials, rationale, and disposition by ethnicity. Benchmark: Comparability across ethnic groups served.
Tracking of access and utilization rates for populations of the four groups across all levels of care in comparison to the covered population. Benchmark: Proportional to covered population.
Consumer and family satisfaction with access and authorization services. Benchmark: 90% satisfaction.

References

Abe-Kim, J.S., & Takeuchi, D.T. (1996). Cultural competence and quality of care: Issues for mental health service delivery in managed care. Clin Psychol Sci Prac, 3, 273-295.

Beaudin, C.L. (1998). Outcomes measurement: Application of performance standards and practice guidelines in managed behavioral healthcare. Journal of Nursing Care Quality, 13, 14-26.

WICHE. (1998). Cultural Competence Standards in Managed Care. Mental Health Services for Four Underserved/Underrepresented Racial/Ethnic Groups. Western Interstate Commission for Higher Education (WICHE) Mental Health Program.

Dana, R.H. (1998). Cultural competence in three human service agencies. Psychological Rep, 83, 107-12.

Hu, T., Snowden, L.R., Jerrell, J.M., & Nguyen, T.D. (1991). Ethnic populations in public mental health: Services choice and level of use. American Journal of Public Health, 81, 1429-1434.

Jones, M.E., Bone, M.L., & Cason, C.L. (1998). Where does culture fit in outcomes management? Journal of Nursing Care Quality, 13, 41-51.

Lavizzo-Mourey, R., Mackenzie, E.R. (1996). Cultural competence: essential measurements of quality for managed care organizations. Annals of Internal Medicine, 15, 919-21.

Table of Contents | Previous