Hello, and welcome to the .Culturally and Linguistically Appropriate Services (CLAS) for Grant Reviewers. webinar.

Many funding organizations require recipients to demonstrate cultural and linguistic competence in their grant applications. This movement toward cultural and linguistic competence stems from our nation.s increasing diversity, long-standing health disparities, and an increased acceptance of cultural and linguistic competency as a means to improve care and services. In addition, the National Institutes for Health and the Agency for Healthcare Research and Quality require the inclusion of minority groups in research.

This session will provide grant reviewers with foundational knowledge about cultural and linguistic competence and the HHS Office of Minority Health.s National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care . also known as the National CLAS Standards. The National CLAS Standards outline 15 strategies for operationalizing cultural and linguistic competence.

This presentation provides an overview of how culturally and linguistically appropriate services may appear in an application or organization. This presentation covers a wide swath of information; it is important to note that not all grant applications will cover all of these Standards. We hope that the Standards serve as a resource and reference for you as you review grants that should address culturally and linguistically appropriate services.

For additional information and guidance on CLAS or the National CLAS Standards, you may consult the Office of Minority Health.s Think Cultural Health website at www.ThinkCulturalHealth.hhs.gov.

The objectives of today.s presentation are:

. To increase knowledge of commonly used terminology around culturally and linguistically appropriate services

. To provide an overview of the enhanced National CLAS Standards

. To describe how the enhanced National CLAS Standards may be operationalized and assessed in grant applications

An e-mail address will be provided at the conclusion of this session; feel free to contact us if you have any questions.

First, let.s cover some of the terminology and concepts that we.re talking about when we discuss culturally and linguistically appropriate services. Please note the specifics and the nuances of the following definitions. As you know, how terms are used in grant applications directly affects how services could or should be provided.

Culture is defined as the integrated pattern of thoughts, communications, actions, customs, beliefs, values, & institutions associated, wholly or partially, with racial, ethnic, or linguistic groups as well as religious, spiritual, biological, geographical, or sociological characteristics.

Culture is dynamic in nature, & individuals may identify with multiple cultures over the course of their lifetimes.

In addition to identifying with multiple cultures over their lifetimes, individuals frequently view the world through multiple cultural lenses simultaneously. If a grant calls for culturally and linguistically appropriate services in general (versus focusing on a specific cultural group or groups), it will be important to think about this broad definition of culture to examine how an organization is seeking to address/implement CLAS.

Therefore organizations may need to consider factors such as accessibility to facilities, literacy level of materials, English proficiency of the service population, hours of operation, or proximity to public transportation.

Language Assistance Services are mechanisms used to facilitate communication with individuals who do not speak English, those who have limited English proficiency, and those who are deaf or hard of hearing.

In a grant application, these services may include in-person interpreters, bilingual staff, or remote interpreting systems such as telephone or video interpreting.

Language services also refer to processes in place to provide translation of written materials or signage, sign language, or braille materials.

In popular media and in society in general, the terms .interpretation. and .translation. are often used interchangeably. It is important to note that these are two distinct fields and require different skill sets.

Interpretation is the process of understanding and analyzing a spoken or signed message and re-expressing that message faithfully, accurately, and objectively in another language, taking the cultural and social context into account. For example, sign language interpretation is a type of interpretation.

Translation is the conversion of a written text into a corresponding written text in a different language faithfully, accurately, and objectively in another language, taking the cultural and social context into account. For example, translating forms or a manual from English to Spanish is an example of translation.

The Office of Minority Health.s National CLAS Standards defines culturally and linguistically appropriate services as:

Services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs and employed by all members of an organization (regardless of size) at every point of contact.

.Every point of contact. is an important element of this definition. CLAS should not be limited to the patient-provider encounter. Rather, culturally and linguistically appropriate services should be integrated at every point of contact that an individual has with an organization. How did the individual hear about the organization or institution? If an individual was trying to contact the organization, were they able to readily do so? If an individual has limited English proficiency, were they able to connect with someone in a language they understood? Upon arriving at the organization or facility, was the individual able to find parking? The entrance? And the appropriate office with relative ease?

The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care were recently re-released by the Office of Minority Health.The grant you are reviewing may call for the provision of culturally and linguistically appropriate services OR it may call for the implementation of the National CLAS Standards, specifically.

The National CLAS Standards outline 15 strategies or means for operationalizing culturally and linguistically appropriate services. Grantees may not have examples of all 15 Standards illustrated in their grant application. This presentation, as well as the National CLAS Standards, provide an overview of how culturally and linguistically appropriate services may appear in an application or organization. We hope that this presentation and the Standards serve as a resource and reference for you as you review grants which could or should address culturally and linguistically appropriate services

In the next section, we will review the National CLAS Standards and discuss the intention behind each of them and provide a few examples of how they might be reflected in a grant application.

There are 15 National CLAS Standards. The Principal Standard provides a foundation for the set of Standards.

The rest of the Standards fall under three themes:

-- Governance, Leadership, and Workforce: this theme emphasizes that implementing CLAS is the responsibility of the entire system. Implementing CLAS really requires the investment, support, and training of all individuals within an organization.

-- Communication and Language Assistance: this theme encompasses all communication needs and services, including sign language, braille, oral interpretation, and written translation.

-- Engagement, Continuous Improvement, and Accountability: this theme focuses on the supports necessary for adoption, implementation, and maintenance of culturally and linguistically appropriate policies and services regardless of one.s role within an organization or practice.

Depending on the grant announcement, certain themes may be more relevant than others. But for an organization (regardless of size) to embody cultural and linguistic competency, it will have had to have thought through and addressed each of the elements featured in the Standards.

The intention of the National CLAS Standards is to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations.

The intention of the National CLAS Standards is to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations.

Standard 1 is the Principal Standard because, conceptually, the ultimate aim in adopting the remaining Standards is to achieve Standard 1.

The purposes of providing effective, equitable, understandable, and respectful quality care and services are:

. To create a safe and welcoming environment at every point of contact that both fosters appreciation of the diversity of individuals and provides patient- and family-centered care.

. To ensure that all individuals receiving health care and services experience culturally and linguistically appropriate encounters.

. To meet communication needs so that individuals understand the health care and services they are receiving, can participate effectively in their own care, and make informed decisions.

. To eliminate discrimination and disparities.

If Standards 2 through 15 are implemented and maintained, organizations will be better positioned to achieve the desired goal of .effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs..

Standard 2 reads: To advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.

The purposes of advancing and sustaining governance and leadership that promotes CLAS and health equity are:

. To ensure the provision of appropriate resources and accountability needed to support and sustain initiatives.

. To model an appreciation and respect for diversity, inclusiveness, and all beliefs and practices.

. To support a model of transparency and communication between the service setting and the populations that it serves.

The operationalization of Standard 2 may include:

. Implementing strategies to recruit, retain, and promote at all levels of the organization a diverse leadership that reflects the demographic characteristics of the populations in the service area.

. Ensuring that the necessary fiscal and human resources, tools, skills, and knowledge to support and improve culturally competent policies and practices in the organization are available.

. Committing to cultural competency through system-wide approaches that are articulated through written policies, practices, procedures, and programs.

Standard 3: Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.

The purposes of recruiting, promoting, and supporting a diverse governance, leadership, and workforce are:

. To create an environment in which culturally diverse individuals feel welcomed and valued.

. To promote trust and engagement with the communities and populations served.

. To infuse multicultural perspectives into planning, design, and implementation of CLAS.

. To ensure diverse viewpoints are represented in governance decisions.

. To increase knowledge and experience related to culture and language among staff.

The operationalizing of Standard 3 may include:

Recruitment

. Advertising job opportunities in targeted foreign language and minority health professional associations. job boards, publications, and other media (e.g., social media networks, professional organizations. email Listservs, etc.), and post information in multiple languages.

. Developing relationships with local schools, training programs, and faith-based organizations to expand recruitment base.

This could include recruiting culturally and linguistically diverse staff (e.g., research assistants, research associates, etc.) to support grant work.

Promotion and Support

. Developing, maintaining, and promoting continuing education, mentoring and career development opportunities so all staff members may progress within the organization.

. Conducting regular, explicit assessments of hiring and retention data, current workforce demographics, promotion demographics, and community demographics.

. Promoting diverse staff members into administrative or managerial positions where their cultural and linguistic capabilities can make unique contributions to planning, policy, and decision-making.

Standard 4: Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

The purposes of educating and training governance, leadership, and workforce in CLAS are:

. To prepare and support a workforce that demonstrates the attitudes, knowledge, and skills necessary to work effectively with diverse populations.

. To increase the capacity of staff to provide services that are culturally and linguistically appropriate.

. To assess the progress of staff in developing cultural, linguistic, and health literacy competency.

. To foster an individual.s right to respect and nondiscrimination by developing and implementing education and training programs that address the impact of culture on health and health care.

The operationalizing of Standard 4 may include:

. Engaging staff in dialogues about meeting the needs of diverse populations.

. Providing ongoing in-service training on ways to meet the unique needs of the population, including regular in-services on how and when to access language services for individuals with limited English proficiency.

. Taking advantage of internal and external resources available to educate governance, leadership, and workforce on cultural beliefs they may encounter.

. Allocating resources to train current staff in cultural competency or as medical interpreters if they speak a second language, have completed language assessments, and show an interest in interpretation.

. Incorporating cultural competency and CLAS into staff evaluations.

Standard 5: Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.

The purposes of offering communication and language assistance are:

. To ensure that individuals with limited English proficiency and/or other communication needs have equitable access to health services.

. To help individuals understand their care and service options and participate in decisions regarding their health and health care.

. To increase individuals. satisfaction and adherence to care and services.

. To improve patient safety and reduce medical error related to miscommunication.

. To help organizations comply with requirements such as Title VI of the Civil Rights Act of 1964; the Americans with Disabilities Act of 1990; and other relevant federal, state, and local requirements to which they may need to adhere.

The operationalization of Standard 5 may include:

. Ensuring that staff is fully aware of, and trained in, the use of language assistance services, policies, and procedures (see Standard 4).

. Developing processes for identifying the language(s) an individual speaks (e.g., language identification flash cards or .I speak. cards) and for adding this information to that person.s health record.

. Using qualified and trained interpreters to facilitate communication, including ensuring the quality of the language skills of self-reported bilingual staff who use their non-English language skills during patient encounters.

. Establishing contracts with interpreter services for in-person, over-the-phone, and video remote interpreting.

Standard 6: Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.

The purposes of informing individuals of the availability of language assistance are:

. To inform individuals with limited English proficiency, in their preferred language, that language services are readily available at no cost to them.

. To facilitate access to language services.

. To help organizations comply with requirements such as Title VI of the Civil Rights Act of 1964; the Americans with Disabilities Act of 1990; and other relevant federal, state, and local requirements to which they may need to adhere.

There are a few strategies that could be employed to effectively inform individuals of the availability of language assistance. When determining the content and languages of the notices, organizations should consider the following:

. Notification should describe what communication and language assistance is available, in what languages the assistance is available, and to whom they are available. It should clearly state that communication and language assistance is provided by the organization free of charge to individuals.

. Notification should be easy to understand at a low literacy level, which is approximately a 5th grade reading level.

When deciding how to communicate or provide notice to individuals about the availability of language services, organizations should consider the following:

. Signage, Materials, and Multimedia: Organizations should reflect the languages regularly encountered in the service area in their signs, materials, and multimedia resources (Berger, 2005; HHS OCR, 2003). For those who may not be literate, information can be conveyed orally or through signage using symbols or pictures (HHS OMH, 2005; Kashiwagi, 2004).

. Cultural Mediation: Another method for promoting quality communication is through the development of a cultural mediation program. A cultural mediator can act as a liaison between the culture of the organization and the culture of the individual.

. Community Outreach: Providing notification throughout the community is also important for reaching those who may be unaware of the organization or what services the organization may provide.

. Initial Point of Contact: It is recommended that organizations standardize procedures for staff members who serve as the initial point of contact for individuals, whether that is by telephone or in person. It may be appropriate to provide staff with a script to ensure that they inform individuals of the availability of language assistance and to inquire whether they will need to utilize any of the available services. Multilingual phone trees and voice mail should also be used to inform individuals of the available language assistance services and how to access them.

Standard 7: Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.

The purposes of ensuring the competence of individuals providing language assistance are:

. To provide accurate and effective communication between individuals and providers.

. To reduce misunderstanding, dissatisfaction, omission of vital information, misdiagnoses, inappropriate treatment, and patient safety issues due to reliance on staff or individuals that lack interpreter training.

. To empower individuals to negotiate and advocate, on their own behalf, for important services via effective and accurate communication with health and health care staff.

. To facilitate the process of obtaining informed consent

. The operationalization of Standard 7 may include an assessment of the individual.s ability to provide language assistance. National organizations such as the American Translators Association and the National Council on Interpreting in Health Care have issued standards of practice that define expectations of performance and outcomes.

. Organizations may provide language assistance according to a variety of models, including bilingual staff or dedicated language assistance such as a contract interpreter or video remote interpreting. A combination of models, or a multifaceted model, offers the organization a comprehensive and flexible system [for] facilitating communication. Under a multifaceted model, for example, telephonic interpreting will supplement the language assistance provided by bilingual staff to ensure that at all times, language assistance is being provided by competent individuals.

Standard 8: Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

The purposes of providing easy-to-understand materials and signage are:

. To ensure that readers of other languages and individuals with various health literacy levels are able to access care and services.

. To provide access to health-related information and facilitate comprehension of, and adherence to, instructions and health plan requirements.

. To enable all individuals to make informed decisions regarding their health and their care and services options.

The operationalizing Standard 8 may include:

. Issuing plain language guidance and create documents that demonstrate best practices in clear communication and information design.

. Creating forms that are easy to fill out, and offer assistance in completing.

. Consulting local librarians to help build an appropriate collection of health materials.

. Training staff to develop and identify easy-to-understand materials, and establish processes for periodically re-evaluating and updating materials.

. Developing materials in alternative formats for individuals with communication needs, including those with sensory, developmental, and/or cognitive impairments.

. Testing materials with target audiences. For example, focus group discussions with members of the target population can identify content in the material that might be embarrassing or offensive, suggest cultural practices that provide more appropriate examples, and assess whether graphics reflect the diversity of the target community.

Standard 9: Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization.s planning and operations.

The purposes of infusing CLAS throughout the organization.s planning and operations are:

. To make CLAS central to the organization.s service, administrative, and supportive functions.

. To integrate CLAS throughout the organization (including the mission) and highlight its importance through specific goals.

. To link CLAS to other organizational activities, including policy, procedures, and decision-making related to outcomes accountability.

The operationalization of Standard 9 may include:

. Engaging the support of governance and leadership, and encourage the allocation of resources to support the development, implementation, and maintenance of culturally and linguistically appropriate services.

. Encouraging governance and leadership to establish education and training requirements relating to culturally and linguistically appropriate services for all individuals in the organization, including themselves.

. Identifying champions within and outside the organization to advocate for CLAS, to emphasize the business case and rationale for CLAS, and encourage full-scale implementation.

Standard 10: Conduct ongoing assessments of the organization.s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities.

The purposes of conducting organizational assessments are:

. To assess performance and monitor progress in implementing the National CLAS Standards.

. To obtain information about the organization and the people it serves, which can be used to tailor and improve services.

. To assess the value of CLAS-related activities relative to the fulfillment of governance, leadership, and workforce responsibilities.

The following are possible implementation strategies for conducting organizational assessments:

. Conduct an organizational assessment or a cultural audit using existing cultural and linguistic competency assessment tools to inventory structural policies, procedures, and practices. These tools can provide guidance to determine whether the core structures and processes (e.g., management, governance, delivery systems, and customer relation functions) necessary for providing CLAS are in place.

. Use results from assessments to identify assets (e.g., bilingual staff members who could be used as interpreters, existing relationships with community-based ethnic organizations), weaknesses (e.g., no translated signage or cultural competency training), and opportunities to improve the organization.s structural framework and capacity to address cultural and linguistic competence in care (e.g., revise mission statement, recruit people from diverse cultures into policy and management positions).

The following are implementation strategies for integrating CLAS-related measures into measurement and continuous quality improvement activities:

. Implement ongoing organizational assessment of CLAS-related activities.

. Conduct focus groups with individuals to monitor progress and identify barriers to full-scale CLAS implementation.

. Assess the standard of care provided for various chronic conditions to determine whether services are uniformly provided across cultural groups.

. Identify outcome goals, including metrics, regarding cultural and linguistic competency and assess at regular intervals.

Standard 11: Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.

The purposes of collecting and maintaining demographic data are:

. To accurately identify population groups within a service area.

. To monitor individual needs, access, utilization, quality of care, and outcome patterns.

. To ensure equal allocation of organizational resources.

. To improve service planning to enhance access and coordination of care.

. To assess and improve the extent to which health care services are provided equitably.

The operationalization of Standard 11 may include properly training staff to collect data, addressing why this information is being collected:

. This information is important.

. It will be used to improve care and services and to prevent discrimination.

. This information will be kept confidential.

. In addition, address any concerns up front and clearly.

Individuals/patients should self-report (i.e., select their own race, ethnicity, language, etc.)

Standard 12: Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.

The purposes of conducting assessments of community health assets and needs are:

. To determine the service assets and needs of the populations in the service areas (needs assessment).

. To identify all of the services available and not available to the populations in the service areas (resource inventory and gaps analysis).

. To determine what services to provide and how to implement them, based on the results of the community assessment.

. To ensure that health and health care organizations obtain demographic, cultural, linguistic, and epidemiological baseline data (quantitative and qualitative) and update the data regularly to better understand the populations in their service areas.

The operationalizing Standard 12 may include:

. Describing the makeup and history of the community to provide a context within which to collect data on its current concerns.

. Describing what matters to people in the community separate from, but in addition to key stakeholders such as what issues are important . safety, education, housing, health, etc.

. Describing the barriers and resources for addressing the identified issue(s).

. (Based on the assessment) Selecting and stating the priority issue (or issues) to be addressed by the organization.

Standard 13: Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.

The purpose of partnering with the community is:

. To provide responsive and appropriate service delivery to a community.

. To ensure that services are informed and guided by community interests, expertise, and needs.

. To increase use of services by engaging individuals and groups in the community in the design and improvement of services to meet their needs and desires.

. To create an organizational culture that leads to more responsive, efficient, and effective services and accountability to the community.

The following are implementation strategies for partnering with the community:

. Partner with local culturally diverse media to promote better understanding of available care and services and of appropriate routes for accessing services among all community members.

. Build coalitions with community partners to increase reach and impact in identifying and creating solutions.

. Convene town hall meetings, hold community forums, and/or conduct focus groups (Prevention by Design, 2006).

. Develop opportunities for capacity building initiatives, action research, involvement in service development, and other activities to empower the community.

. Collaborate to reach more people, to share information and learn, and to improve services. Work with partners to advertise job openings, identify interpreting resources, and organize health promotion activities. Successful partnerships benefit all.

In addition, the following professionals and volunteers may facilitate communication between an organization and the community it serves:

. Promotores de salud/community health workers are volunteer community members and paid front-line public health workers who are trusted members of the community served or have an unusually close understanding of that community. Community health workers serve as liaisons, links, or intermediaries between health and social services and the community to facilitate access to and enrollment in services and improve the quality and cultural competency of services (HHS OMH, 2011).

Standard 14: Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.

The purposes of creating conflict and grievance resolution processes that are culturally and linguistically appropriate are:

. To facilitate open and transparent two-way communication and feedback mechanisms between individuals and organizations.

. To anticipate, identify, and respond to cross-cultural needs.

. To meet federal and/or state level regulations that address topics such as grievance procedures, the use of ombudspersons, and discrimination policies and procedures.

The operationalizing of Standard 14 may include:

. Providing cross-cultural communication training, including how to work with an interpreter, and conflict resolution training to staff who handle conflicts, complaints, and feedback.

. Providing notice in signage, translated materials, and other media about the right of each individual to provide feedback, including the right to file a complaint or grievance.

. Developing a clear process to address instances of conflict and grievance that includes follow-up and ensures that the individual is contacted with a resolution and next steps.

. Obtaining feedback via focus groups, community council or town hall meetings, meetings with community leaders, suggestion and comment systems, open houses, and/or listening sessions.

Standard 15: Communicate the organization.s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

The purposes of communicating the organization.s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public are:

. To convey information to intended audiences about efforts and accomplishments in meeting the National CLAS Standards.

. To learn from other organizations about new ideas and successful approaches to implementing the National CLAS Standards.

. To build and sustain communication on CLAS priorities and foster trust between the community and the service setting.

. To meet community benefits and other reporting requirements, including accountability for meeting health care objectives in addressing the needs of diverse individuals or groups.

The operationalization of Standard 15 may include:

. Drafting and distributing materials that demonstrate efforts to be culturally and linguistically responsive.

. Partnering with community organizations to lead discussions about the services provided and progress made.

. Creating advisory boards to consult with community partners on issues affecting diverse populations and how best to serve and reach them.

. Engaging community-based workers to help craft and deliver messages and implications of data. Community outreach that is culturally and linguistically tailored and provided by trusted messengers is central to ensuring messages are received, understood, and adhered to by local members of the community. Community-based workers are seen as trusted sources of health information and can help with reaching and educating communities (National Consensus Panel on Emergency Preparedness and Cultural Diversity, 2011).

If you would like additional information on culturally and linguistically appropriate services, there are many resources out there, including the following:

The Blueprint is the accompanying guidance document for the National CLAS Standards and was designed to provide individuals, agencies and organizations of all kinds the guidance to implement the National CLAS Standards.

The Blueprint contains the Case for CLAS and Standard by Standard chapters, which greatly expand on the information provided in this session.

Think Cultural Health is a website from the HHS Office of Minority Health that houses many of the offices cultural and linguistic competency policy and education related initiatives including:

Suite of e-learning programs . free, on-line continuing education

CLAS Clearinghouse . key word searchable database of resources

Join the CLCCHC . e-newsletter, calendar, and other educational materials

National CLAS Standards & The Blueprint