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Workshop
B-5: National quality organizations interpret the CLAS standards: a focus
group discussion
Panelists:
- Lok Wong, MHS, Senior Health Care Analyst, Quality Measurement
- National Committee for Quality Assurance
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- Amy Wilson, MPP, CPHQ, Associate Project Director, Division
of Standards and Survey Methods
- Joint Commission on Accreditation of Healthcare Organizations
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- Helen Wu, MSc, Program Director
- National Quality Forum
Abstract:
In December 2000, the U.S. Department of Health and Human Services’
Office of Minority Health issued 14 recommendations for Culturally and
Linguistically Appropriate Services (CLAS). Since then, many have looked
to the CLAS standards for guidance on improving care for diverse populations,
and some healthcare organizations have made efforts to implement the standards
to provide more culturally competent care. However, the adoption and use
of CLAS on a national scale has not yet occurred, which presents a clear
opportunity for key policymakers to coordinate their efforts to improve
the quality of care for these populations. This session will focus on
the roles of three major national healthcare quality organizations –
The Joint Commission on Accreditation of Health Care Organizations (JCAHO),
The National Committee on Quality Assurance (NCQA), and The National Quality
Forum (NQF) – in educating the field and promoting broad change in
healthcare organizations for better culturally and linguistically competent
care. Panelists will provide an overview of their respective organizations’
general mechanisms for promoting change in healthcare organizations and
their current projects for culturally diverse populations, and they will
stimulate an audience discussion to explore the potential pathways for
their organizations to improve culturally competent care by setting standards,
implementing performance measures, or using other strategies to achieve
change on a broad scale.
General
Issues for Discussion:
- What is your organization doing to improve culturally competent care?
What strategies have you used and what barriers have you encountered
in trying to implement strategies to improve culturally competent care
at your organization?
- What are your perspectives on the CLAS standards and other guidelines
for providing culturally care? What could be done to facilitate widespread
adoption and implementation of the CLAS standards by healthcare organizations?
- What can organizations like JCAHO, NCQA, and NQF do to encourage
healthcare organizations to provide culturally and linguistically appropriate
services? What kinds of strategies, both regulatory and non-regulatory,
would be effective and feasible to implement?
National
Committee for Quality Assurance (NCQA)
 National
attention has been focused on health disparities and barriers to accessing
health care for the underserved population. The ability of health care
organizations to deliver appropriate health care services and quality
improvement interventions for diverse populations has been identified
to be of crucial importance to reducing health disparities and to provide
adequate access to care for various sub-populations. Managed care organizations
(MCOs), as third-party payers and coordinator of services have a large
role to play in both the delivery of health care services and providing
access to health care services for diverse populations; from providing
culturally and linguistically appropriate information on health information
as well as materials on the MCO’s health benefits and services, directing
members to culturally competent office staff and providers for appointment
scheduling and providing interpretation services for the health care visit,
treatment and medication directions. However the tools and methods available
to MCOs for evaluation and assessment that can generate public accountability
as well as encourage quality improvement are still in their infancy.
NCQA Projects
on Health Disparities and Culturally and Linguistically Appropriate Services
To address national interest in the quality of care received by diverse
populations, the National Committee for Quality Assurance is working on
two projects funded by the California Endowment Foundation to explore
the state-of-the-art on measuring and assessing the delivery of culturally
and linguistically appropriate services by managed care organizations
to their diverse populations and how to address health disparities.
Project
1. Measuring and Assessing Linguistically and Culturally Appropriate Services
(CLAS) in Managed Care for Public Accountability
(1) The first project is a feasibility study to determine how
to evaluate and assess MCOs’ provision of culturally and linguistically
appropriate services (CLAS) to their diverse populations using quality
standards or performance measures given the current state-of-the-art.
Qualitative interviews will be conducted with key stakeholders and managed
care organizations to identify methods for evaluating MCO’s delivery
of culturally and linguistically appropriate services (CLAS). With input
from an expert advisory panel, NCQA will develop recommendations for potential
new or revised standards or performance measures and other policy recommendations
to encourage managed care organizations to effectively deliver appropriate
services to their linguistically, racially and ethnically diverse populations.
Project
2. Using Quality Measurement to Address Disparities in Health Care: Medicare
+ Choice HEDIS Race/Gender Analysis
(2) The second project is to investigate public reporting of
HEDIS performance measures in clinical areas to help health plans monitor
and address clinical health disparities among their enrollees. We are
conducting quantitative analyses to explore race and gender differences
using Medicare + Choice plans’ HEDIS data on 16 quality of clinical
care indicators. The quantitative findings will be reviewed by the expert
panel convened in the first project so that a wider discussion and set
of recommendations can be formulated on the feasibility of stratified
reporting of HEDIS measures by race/ethnicity and gender, and the development
of performance measures to assess culturally and linguistically appropriate
services.
The findings from the two projects will inform NCQA and others on the
feasibility of evaluating CLAS and Health Disparities in managed care
organizations based on the current state-of-the-art and evidence in these
areas. Findings from the two projects will be disseminated in a final
report and workshop in 2005.
Organizational Background
The National Committee for Quality Assurance (NCQA) is a private, not-for-profit
organization dedicated to improving health care quality. Through NCQA’s
Accreditation programs for managed care and the deployment of the Health
Plan and Employer Data Information Set® (HEDIS) – a set of performance
measures for managed care organizations, NCQA evaluates the quality of
care and encourages appropriate processes of care, including measures
of clinical quality, access to care, and members’ experience of care
through the Consumer Assessment of Health Plan Survey (CAHPS).
NCQA’s past involvement in CLAS-related projects includes participation
on various taskforces to provide input on the development of national
standards on CLAS, including the advisory committee to develop the National
CLAS standards sponsored by the DHHS Office of Minority Health, the technical
expert panel for the HRSA study on Measuring Cultural Competence in Health
Care Delivery Settings.
Lok Wong, M.H.S., Senior Health Care Analyst, Quality Measurement,
National Committee for Quality Assurance
Through NCQA’s clinical expert panels, Ms. Wong leads the development
of new quality of care measures in areas such as geriatric health, appropriate
medications, access to care and women’s health. In addition, she
manages various research projects related to quality of care including
cultural and linguistic competency, and health disparities.
Prior to her current role in Quality Measurement at NCQA, Ms. Wong held
the position of Health Care Analyst in Product Development where she worked
on developing a Disease Management Accreditation program. Her interest
in health services research and public accountability was fostered at
Johns Hopkins School of Public Health where she gained her Masters of
Health Science in Health Policy and Management. In addition, Ms. Wong
has community experience in patient advocacy and outreach, dealing with
issues from access for minority populations to oncology care and HIV prevention.
Lok Wong, MHS
Senior Health Care Analyst,
Quality Measurement
National Committee for Quality Assurance
2000 L Street, NW, Suite 500
Washington D.C. 20036
Tel: 202-955-1784
Fax: 202-955-3599
wong@ncqa.org
www.ncqa.org
References
1 Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting
racial and ethnic disparities in health care. Washington D.C: Institute
of Medicine, National Academy Press, 2002.
1 Karen Scott Collins et al, Diverse Communities, Common Concerns: Assessing
Health Care Quality for Minority Americans – Findings from the Commonwealth
Fund 2001 Health Care Quality Survey, Commonwealth Fund, March 2002
1 Fortier JP, Shaw Taylor Y, Cultural and Linguistic Competence Standards
and Research Agenda Project, Part One: Recommendations for National Standards,
May 1999
The Joint
Commission on Accreditation of Health Care Organizations
Overview
The Joint Commission evaluates and accredits more than 15,000 health care
organizations and programs in the United States. As an independent not-for-profit
accrediting body the Joint Commission maintains state-of-the-art standards
that focus on improving the quality and safety of care provided by health
care organizations. The Joint Commission's comprehensive accreditation
process evaluates an organization's compliance with these standards and
other accreditation requirements. The Joint Commission maintains accreditation
programs for hospitals, ambulatory care, home care, long term care, behavioral
health care, laboratory, and health care network programs.
Joint Commission accreditation is recognized nationwide as a symbol
of quality that reflects an organization's commitment to meeting certain
performance standards. To earn and maintain the Joint Commission's Gold
Seal of Approval™, an organization must undergo an on-site survey
by a Joint Commission survey team at least every three years. Laboratories
must be surveyed every two years.
The Joint Commission is governed by a 29-member Board of Commissioners
that includes nurses, physicians, consumers, medical directors, administrators,
providers, employers, a labor representative, health plan leaders, quality
experts, ethicists, a health insurance administrator and educators. The
Board of Commissioners brings to the Joint Commission countless years
of diverse experience in health care, business and public policy. The
Joint Commission's corporate members are the American College of Physicians,
the American College of Surgeons, the American Dental Association, the
American Hospital Association and the American Medical Association. The
Joint Commission employs more than 1,000 people in its surveyor force,
at its central office in Oakbrook Terrace, Illinois, and at a satellite
office in Washington, DC.
Standards and Survey Process
Joint Commission standards address the organization's level of performance
in key functional areas, such as patient rights, patient treatment, and
infection control, and the standards focus not simply on an organization's
ability to provide safe, high quality care, but on its actual performance
as well. Standards set forth performance expectations for activities that
affect the safety and quality of patient care. If an organization does
the right things and does them well, there is a strong likelihood that
its patients will experience good outcomes. The Joint Commission develops
its standards in consultation with health care experts, providers, measurement
experts, purchasers and consumers.
The Joint Commission survey process is designed to provide a systems
level evaluation of an organizations operations focusing on the provision
of patient care. A patient tracer activity takes the surveyor through
the course of a patient’s care within the organization. The surveyor
spends much more time on the floor speaking with staff and less time simply
reviewing documents providing a more representative assessment of patient
care services to be made.
Joint Commission Commitment to the Provision of Culturally and Linguistically
Appropriate Services
“The delivery of culturally competent services is more than
simply a patient’s right, but in fact a key factor in the safety
and quality of patient care.”
Paul Schyve, M.D, Senior Vice President, Joint Commission
The Joint Commission has long held the view that consideration and respect
for patients’ values, beliefs, and language needs are fundamental
to patients' rights. As issues of patient safety and medical errors have
been linked to communication and patient-centered care, the Joint Commission
now views these fundamental rights as key elements of safe, high quality
health care. Many Joint Commission patient safety initiatives now include
consideration of patient’s language needs and the cultural sensitivity
training provided to organization staff.
Joint Commission Activities Related to the Provision of Culturally
and Linguistically Appropriate Services
- Hospitals, Language, and Culture: A Snapshot of the Nation,
a project funded by The California Endowment. Based on feedback received
from health care providers, provider organizations, and Joint Commission
surveyors, hospitals do not feel prepared to be held to the National
Culturally and Linguistically Appropriate Services standards.1
However, there must exist a middle ground whereby hospitals can be expected
to provide culturally and linguistically appropriate services within
their scope of services and their available resources. The Joint Commission
plans to gather information from a sample of hospitals to assess the
capability to address the issues of language and culture as they affect
patient safety and quality care. The information gained will help inform
future efforts of the Joint Commission’s standards and survey method
development, and will aid the Joint Commission in recommending practices
for hospitals to employ in order to make their services more culturally
and linguistically appropriate.
- Understanding Adverse Events in Minority Patients with Limited
English Proficiency, a project funded in part by The Commonwealth
Fund. The purpose of this study is to investigate the epidemiology of
adverse events and near misses attributed to patient-provider communication
problems related to language barriers and to implement intensive quality
improvement interventions for limited English proficiency patients.
- Detailed Review of Joint Commission Standards The Joint Commission
standards supporting the provision of culturally and linguistically
appropriate services are found throughout Joint Commission accreditation
manual chapters; there is not one designated place for these standards.
The Joint Commission views this issue as one that must be addressed
and embedded within all of the functions of the organization.
- Joint Commission Surveyor Education One of the most frequently
cited recommendations for improving the care provided to diverse populations
and eliminating disparities, is raising awareness of the issues. In
2003, the Joint Commission began an effort to increase the awareness
of this issue in its surveyor cadre. A needs assessment was conducted,
and two distance learning educational programs were developed. Surveyors
were provided with an overview of the legal and regulatory supports
for the provision of language access services by the National Health
Law Program. Surveyors were also provided a refresher course on Joint
Commission standards addressing language services and patient-centered
care. Lastly, the learning modules focused on resources that could be
provided by surveyors to the organizations that they survey as part
of the surveyors consultative role. The commitment to raise awareness
to the field of this issue continues as the Joint Commission looks at
other mechanisms for educating surveyors so that they may inform the
field.
Amy Wilson, M.P.P., C.P.H.Q., is an Associate Project Director
in the Division of Standards and Survey Methods and is currently the Principal
Investigator for the Joint Commission study Hospitals, Language, and Culture:
A Snapshot of the Nation. Ms. Wilson earned her Master of Public Policy
in Health Policy and a Graduate Certificate in Health Administration and
Policy from the University of Chicago. Her studies explored poverty, health
inequalities, and health status. She is a Certified Professional in Healthcare
Quality (CPHQ) and is responsible for the development and maintenance
of Joint Commission standards and survey processes. Ms. Wilson has been
a leader in the Joint Commission’s initiatives related to cultural
and linguistic issues in health care. She conducted an assessment of Joint
Commission Surveyors’ opinions and observations related to culturally
and linguistically appropriate health care services and developed a two-part
surveyor training program to address issues of language and culture that
may be identified during Joint Commission surveys. She represents the
Joint Commission on a number of National Advisory Committees on subjects
related to the provision of culturally and linguistically appropriate
services.
Amy L. Wilson, M.P.P., C.P.H.Q.
Associate Project Director
Division of Standards and Survey Methods
Joint Commission on the Accreditation of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
630-792-5954
Fax: 630-792-4954
awilson@jcaho.org
http://www.jcaho.org/about+us/hlc/index.htm
US Department of Health and Human Services, Office of
Minority Health, National Culturally and Linguistically Appropriate Services
in Health Care Standards, were released in March 2001.
National
Quality Organizations and the CLAS Standards: The National Quality Forum’s
Role
Overview
The National Quality Forum (NQF) is a private, not-for-profit, open membership,
public benefit corporation. Its mission is to improve U.S. healthcare
quality through the endorsement of consensus-based national standards
for measurement and public reporting of healthcare performance data that
provide meaningful information about whether care is safe, timely, beneficial,
patient-centered, equitable, and efficient. NQF functions as a unique
“honest broker,” convening healthcare’s many stakeholders
in focused activities to address specific healthcare quality issues. The
NQF is a voluntary consensus standards setting organization pursuant to
the National Technology Transfer Advancement Act (NTTAA) and OMB Circular
A-110.
A shared sense of urgency for valid, reliable and standardized healthcare
performance measures to support and advance public accountability, quality
improvement efforts, increased patient safety, and value-based purchasing
prompted leaders in the public and private sectors to create NQF in 1999.
Established as a public-private partnership and public benefit corporation
following the recommendation of the President’s Advisory Commission
on Consumer Protection and Quality in the Health Care Industry in 1998,
NQF has broad participation from all parts of the healthcare system, including
national, state, regional, and local groups representing consumers; public
and private purchasers; physicians, hospitals and other providers; accrediting
bodies; supporting industries; and organizations involved in healthcare
research or quality improvement. Together, the members of NQF promote
a common approach to measuring and reporting healthcare quality and fostering
system-wide improvements in patient safety and healthcare quality.
Goals. NQF has strategic and specific goals. To accomplish its
mission, NQF strives to have:
- NQF-endorsed standards become the primary standards used to measure
the quality of healthcare in the United States
- NQF become the principal body that endorses national healthcare performance
measures, quality indicators and/or quality of care standards
- NQF increase the demand for high-quality healthcare
- NQF recognized as a major driving force for and facilitator of continuous
improvement of U.S. healthcare quality
The specific goals of NQF are:
- Promote collaborative efforts to improve the quality of the nation’s
healthcare through performance measurement and public reporting
- Develop a national strategy for measuring and reporting healthcare
quality
- Standardize healthcare performance measures so that comparable data
are available across the nation (i.e., establish national voluntary
consensus standards)
- Promote consumer understanding and use of healthcare performance
measures and other quality information
- Promote and encourage the enhancement of system capacity to evaluate
and report on healthcare quality
Members.
NQF is primarily an “organization of organizations” and currently
membership includes over 230 groups. Each NQF member belongs to one of
four Member Councils: Consumers, Providers and Health Plans, Purchasers,
or Research/ Quality Improvement Organizations. All four Councils have
an equal voice and vote in establishing the voluntary consensus standards
developed through the NQF Consensus Development Process. Any organization
is eligible for membership in the NQF. A decision to become a member affirms
the organization’s commitment to quality and acknowledges NQF’s
value as a means to: improve the quality of healthcare; improve the methods
by which healthcare quality is measured and reported; and improve the
public’s capacity to evaluate healthcare on the basis of quality,
and a purchaser’s and the individual’s consumer’s ability
to make healthcare choices based upon information about quality.
Board of Directors.
NQF is governed by a Board of Directors representing healthcare consumers,
employers, purchasers, payers, physicians, nurses, hospitals and other
providers, health plans, and experts in health services research. The
Board has representatives from both the private and public sectors, including
the Centers for Medicare & Medicaid Services, Joint Commission on
Accreditation of Healthcare Organizations, and National Committee for
Quality Assurance. The Board includes the chair of each Member Council,
and the composition of the Board must maintain a consumer-purchaser majority.
NQF Processes and Products.
The NQF’s Consensus Development Process is a formal process to establish
voluntary consensus standards pursuant to the NTTAA and OMB Circular A-110.
As such, NQF endorsement of a set of standards confers upon them a unique
legal status that allows them to be readily adopted by Federal bodies
such as the Centers for Medicare and Medicaid Services. In addition to
projects that lead to consensus standards, the NQF also convenes workshops
and other forums to promote healthcare quality.
NQF Projects
Related to Diverse Populations:
- Improving Use of Prescription Medications (ongoing). The project
will evaluate strategies to improve medication compliance for all U.S.
healthcare consumers, but has a special focus on high-risk populations,
such as culturally and linguistically diverse and low literacy groups.
It will: 1) review the evidence for practices to improve consumer medication
compliance; 2) develop a comprehensive framework for identifying and
implementing a set of practices to improve medication compliance on
a national scale; and 3) convene an October 2004 workshop to agree upon
a national action plan for broadly improving medication compliance and
identify NQF’s role in implementing the plan.
- Improving Patient Safety Through Informed Consent in Limited English
Proficiency and Low Literacy Populations (ongoing). Many patients
face barriers to fully understanding information about the medical treatments
and procedures they consent to receiving, particularly those patients
with communication and literacy challenges. This project will investigate
the barriers to, and strategies for, successfully implementing the NQF-endorsed
practice for informed consent, “ask each patient or legal surrogate
to recount what he or she has been told during the informed consent
discussion,” with a particular emphasis the needs of LEP and low
literacy groups. The project culminated in a September 2004 workshop,
and a user’s guide to assist providers in implementing the practice
is in development.
- Improving Healthcare Quality for Minority Populations: Workshop
Proceedings (National Quality Forum, Washington, DC: 2002).
The need to assess healthcare quality measures specific to minority
populations is critical due to the significant disparities that persist
for these groups. In 2001, NQF convened a group of experts to address:
1) whether there are or should be measures to assess healthcare quality
specifically for minority populations; 2) if existing, general quality
measures are appropriate for minority populations; and 3) what special
challenges arise in collecting and reporting healthcare quality data
for minority populations. The project resulted in ten priority actions
that have formed the underlying foundation for NQF’s overall efforts
for improving healthcare quality for all.
Selected NQF-endorsed Standards Related to Diverse Populations:
- Performance Measures for Hospital Care: A Consensus Report
(National Quality Forum, Washington, DC: 2003). Growing interest
in quality measurement by various stakeholders has given way to many
misdirected or redundant activities, conflicting demands by different
interests, and confusion about relevant measures. This project assessed
and endorsed an initial set of 39 measures in 8 priority areas for public
reporting and quality improvement to be used by consumers, purchasers,
hospitals, and others, that was designed to become a single standard
for measuring acute hospital care performance and to replace the redundant
and conflicting sets used by other national and state-level quality
measurement entities. The criteria and priorities used to select the
measure set included the degree of variation in quality for different
racial/ethnic groups, and the importance of the area in eliminating
known disparities in care.
- A Comprehensive Framework for Hospital Care Performance Evaluation:
A Consensus Report (National Quality Forum, Washington, DC: 2003).
This report, developed to supplement Performance Measures for Hospital
Care, established a comprehensive framework and standardized process
for hospital quality measurement and reporting. The report integrates
mechanisms to address the needs of vulnerable populations, such as racial
and ethnic minorities, throughout the framework, and in doing so ensures
that the needs of these groups are not marginalized, but rather embedded
in the larger quality issues and priorities for improvement that will
be acted upon by all stakeholders.
Ms. Wu is a Program Director for the National Quality Forum,
an organization that establishes voluntary consensus standards for healthcare
quality measurement and reporting. She leads all NQF work in minority
healthcare quality, including its current projects on improving patient
safety through informed consent and improving medication adherence for
communication-challenged groups such as those with limited English proficiency
or low health literacy. Ms. Wu led the work on and was lead author of
the NQF report, Measuring and Reporting Healthcare Quality for Minority
Populations. She has served on expert committees and presented on minority
healthcare quality issues for various national groups, including the U.S.
Office of Minority Health, Agency for Healthcare Research and Quality,
American Osteopathic Association, and Institute of Medicine. She earned
a MSc from the University of Virginia in health evaluation sciences, specializing
in health services research and outcomes evaluation, and a BA from the
University of Virginia in philosophy with a minor in biomedical ethics.
Helen W. Wu, MSc
Program Director
National Quality Forum
601 13th St. NW, Suite 500N
Washington, DC 20005
Phone: 202-783-1300; Fax: 202-783-3434
hwu@qualityforum.org
http://www.qualityforum.org
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