Good afternoon, everyone. Thank you so much for joining us. Today's webinar is the National CLAS Standards in Action. And we have really great information that we're going to be sharing with you. Our panelists are going to include Dr. Gracia of the Office of Minority Health at the US Department of Health and Human Services.

We have Matilde Roman from the New York City Health and Hospitals, James Williams from the University of Chicago Medicine, and Katie Meehan from the Washington State Department of Health.

Just a couple of housekeeping items to you all before we begin, we will be taking some time for a question-and-answer period once the presenters have gone through their presentations. And so you will notice that on the bottom left-hand corner of your screen, you will have the opportunity to enter a question into the chat box.

Please feel free to enter questions throughout the webinar, or if you'd like to wait until the end of the presenters, you are welcome to do that as well.

We are going to have about 10 minutes to go through questions. So if we don't have the opportunity to answer your question, please know that we'll have contact information listed at the end of the presenters' presentations where you'll be able to send us any additional questions that may come up.

So without further ado, I'd like to welcome all of you. Thank you so much for taking the time to be with us. And I'd like to also welcome Dr. Nadine Gracia.

She's a deputy assistant secretary for Minority Health, and the Director of the Office of Minority Health at the US Department of Health and Human Services. Welcome, Dr. Gracia.

Thank you, Lili, and hello to all of you. The individual who was just speaking with you is Liliana Ranon, who is the Associate Director for Policy in the Office of Minority Health at the US Department of Health and Human Services.

And she serves as our project director for the Center for Linguistic and Cultural Competency in healthcare. So we're very pleased to have Lili with us and serving as the moderator for the webinar today.

I want to thank you for joining today's webinar about the National Standards for Culturally and Linguistically Appropriate Services in health and healthcare, which are more simply known as the National CLAS Standards.

You know, we always say that CLAS, or culturally and linguistically appropriate services, is a journey, not a destination. Each of you may approach CLAS from different directions and follow different paths.

But what matters is that you're on this journey. You're all striving to provide the best possible services and high-quality services to everyone. What also matters when you're on a journey, of course, is to have a roadmap.

So today's webinar is the second in a series of webinars about the National CLAS Standards that is being hosted by the HHS Office of Minority Health.

The first webinar that we held in March, discussed the fundamentals of the National CLAS Standards. And in case you missed that webinar, you can view a recording on our website ThinkCulturalHealth.hhs.gov. So the focus of today's webinar, the National CLAS Standards in Action, is an opportunity to share with you three organizations' roadmaps for providing CLAS.

The three panelists are going to explain and discuss what it looks like to implement the National CLAS Standards in different types of health settings. So we're going from the what to the how.

First, we have an integrated healthcare system in New York City; secondly, an academic medical center in Chicago; and third, a public health department in Washington State. These presenters will share with you their successes, best practices and strategies, as well as some of the challenges for the meeting the needs of all the individuals and communities that they serve, regardless of their cultural background or communications needs.

We hope that this webinar will offer you some concrete practical ways to implement the National CLAS Standards at your organization, and to guide you along your own CLAS journey. And as Lili mentioned, after the presentations, we'll have a question-and-answer session.

So before I turn to the presenters, I want to make sure that we all have the fundamental understanding of CLAS and the National CLAS Standards. And so I'm just going to do a brief overview of CLAS and the standards themselves.

CLAS is an acronym that stands for culturally and linguistically appropriate services. It's defined as services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs.

CLAS should be employed by all members of an organization, regardless of size at every point of contact.

Now we know that a one-size-fits-all approach is not the best approach to healthcare and public health. And implementing CLAS helps health and human services professionals treat individuals with respect, and to be mindful of their culture and language.

During this time of remarkable transformation in the healthcare delivery system and in public health, CLAS makes good business sense. Because it helps improve the quality of services, can boost and organization's bottom line and competitiveness in the marketplace, while reducing costly medical errors and risk of liability.

From a social justice perspective, it's also the right thing to do. CLAS is an important way to help reduce health and healthcare disparities because it helps overcome cultural and linguistic barriers, which can lead to poor quality of care and services, and poor health outcome.

So to operationalize the concepts of CLAS, the Office of Minority Health developed the National CLAS Standards, which provide a concrete set of recommendations and action steps that guide professionals and organizations in providing CLAS.

The National CLAS standards are intended to advance health equity, improve quality, and help eliminate health disparities.

So the standards really serve as a great tool and resource for organizations and individuals, as you strive to meet quality improvement goals, requirements for accreditation, and specific legislative and regulatory mandates in the provision of health services.

Now, I'll just go briefly over the standards themselves, and you can refer to the handout section on your screen with a PDF that's named, the National CLAS Standards. This will give you a list of the standards, which will be handy for you for reference during today's presentation.

The standards are structured to include a principle standard that serves as the foundation for all other standards. The rest of the standards are divided into three themes. The governance, leadership, and workforce theme emphasizes that implementing CLAS is the responsibility of the entire health system.

The communication and language assistance theme covers all communication needs and services, including sign language, braille, oral interpretation and written translation. The engagement, continuous improvement, and accountability theme focuses on the supports necessary for adoption, implementation, and maintenance of CLAS.

So starting out with the principle standard which is shown here, it frames the essential goal of all of the standards. Conceptually, if the other 14 standards are adopted, implemented, and maintained, then the principle standard will be achieved, providing effective, equitable, understandable, and respectful quality care and services that help 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. That helps to ensure that all individuals receiving healthcare and services experience culturally and linguistically appropriate encounters.

That helps to meet communication needs so that individuals understand the healthcare and services that they are receiving, can participate effectively in their own care, and can make informed decisions, and that it also helps to eliminate discrimination and disparities.

The governance, leadership, and workforce theme emphasizes that implementing CLAS really requires the investment, support, and training of all individuals within an organization. As you can see, standard 2 address governance and leadership.

Standard 3 addresses recruiting, promoting and supporting a diverse governance, leadership, and workforce. And standard 4 addresses educating and training governance, leadership, and workforce.

The communication and language assistance theme broadens the understanding and application of appropriate services to include all communication needs and services, including sign language, braille, oral interpretation, and written translation.

The standards in this theme will help organizations comply with requirements such as Title IV 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.

Standard 5 addresses offering language assistance. Standard 6 specifically addresses informing individuals of the availability of language assistance services.

Standard 7 addresses ensuring the competence of the individuals who are providing language assistance. And standard 8 addresses providing easy-to-understand materials and signage.

In the engagement, continuous improvement, and accountability theme, it underscores the importance of establishing both individual and organizational responsibility for implementing CLAS. Effective delivery of CLAS demands actions across an organization.

This theme focuses on the supports that are necessary for adoption, implementation, and maintenance of culturally and linguistically appropriate policies and services, regardless of one's role within an organization or practice. All individuals are accountable for upholding the values and intent of the National CLAS Standards.

So with standard 9, it addresses infusing CLAS throughout the organization's planning and operations. Standard 10 addresses conducting organizational assessments. And standard 11 addresses collecting and maintaining demographic data.

Continuing in the engagement, continuous improvement, and accountability theme are standards 12 through 15, with standard 12 addressing conducting assessments of community health assets and needs.

Standard 13 addressing partnering with the community. Standard 14 addresses creating conflict and grievous resolution processes that are culturally and linguistically appropriate. And standard 15 addresses communicating the organization's progress.

So with that background on the National CLAS Standards and a brief overview of the National CLAS Standards, I'm very excited to introduce our panel of presenters for today's webinar. As I mentioned earlier, you're going to hear concrete examples of how to implement the National CLAS Standards from today's speakers.

Our first example will demonstrate this for the integrated healthcare system. Our first speaker today is Matilde Roman, who is a graduate of New York's Law School. She is an executive manager at the New York City Health + Hospitals, where she designs, implements, and manages systems that promote diversity, inclusion, and the delivery of equitable care.

Ms. Roman provides leadership in developing strategic diversity and inclusion initiatives that support employee development and advancement opportunities, and policies and programs that promote access and health equity through the delivery of language services and culturally responsive care.

New York City Health and Hospitals is the largest municipal healthcare system in the country, with a network of 11 acute hospitals, five skilled nursing facilities, six Gotham health centers, and more than 70 community-based clinics that serve 1.2 million patients annually. Matilde, welcome to the webinar, and I'll turn it over to you.

Thank you so much, Dr. Gracia, and thank the Office of Minority Health for giving me this opportunity to speak to you today. Today, I want to provide you with an organizational framework for implementing the CLAS Standards, based on New York City Health and Hospital's journey to advance health equity.

During the next 20 minutes I plan to give you an overview of New York City Health and Hospitals, tell you a bit about the Office of Diversity & Inclusion that essentially administers the CLAS Standards, help bring (ph) some key elements to facilitate implementation of these standards,

provide you with some real-time examples of our experience to put these elements into context and perspective, and highlight for you some of our successes, lessons learned, and opportunities for growth.

So as Dr. Gracia had mentioned, Health and Hospitals is the largest municipal healthcare delivery system in the country, serving approximately 1.2 million New Yorkers annually. And as a safety net hospital for New York City, we promote health equity to eliminate health disparities through culturally responsive care and language services.

Our mission is to provide meaningful access to comprehensive health services to all New Yorkers, regardless of a person's immigration status, language spoken, or ability to pay.

Our CEO and President, Dr. Ram Raju, is listed among the top-100 most influential people in healthcare, and Chairs AHA's Equity of Care Committee. And he has spent the last 15 years advancing health equity agenda.

Some notable examples of the type of quality care provided and Health and Hospitals include our response to Ebola, and caring for celebrities like Jimmy Fallon from "The Tonight Show," who praised the care team at Bellevue that successfully reattached his finger.

Also worth mentioning how much of our work is outward focused, to help the most vulnerable in our community, working to address social determinants that affect health outcomes in urban communities, like efforts to combat gun violence, making available fresh fruits and vegetables, and providing access to legal representation.

The importance of advancing culturally responsive and linguistically appropriate services is clear when you look at New York City's composition. Nearly 40% of New Yorkers are foreign born.

Half a million are undocumented. New York City is one of the few cities in the country in which four different racial ethnic groups each make up at least 10% of the population, and it's home to the largest LGBT community in the country.

In New York, over 200 languages are spoken by city residents. 50% of all New Yorkers speak a language other than English at home. And nearly 1.8 million residents are considered limited English proficient. So wherever you are in this country, you are seeing the shifting demographic composition of the United States.

The US Census projects that by the end this decade, no single racial or ethnic group will constitute a majority of children under 18. And in about three decades, no single group will constitute a majority of the country as a whole.

The new projections paint a picture of a nation whose population is growing more slowly than anticipated, where the elderly is expected to make up a growing share of the populous, and is rapidly becoming more racially and ethnically diverse. And all of these trends promise to shape our healthcare delivery system in the decades to come.

So let me begin by walking you through some of these key elements. The first key element is to create an organizational structure to advance the work through central administration and oversight.

Beginning in 2007, Health and Hospitals established a central office to provide expert resources to support system-wide efforts to implement best practices and improve the delivery of language services and culturally responsive care across the organization.

The department, formerly called the Office of Culturally and Linguistically Appropriate Services, is now called the Office of Diversity & Inclusion. It's located within central office, and reports directly to the Executive Vice President and Chief Operating Officer of the organization.

The work is intended to advance and sustain governance and leadership to promote CLAS, and help equity as per CLAS Standard 2. Not only do we do have a central coordinating body here at central office, we also have key positions at the facility level.

As an example, because the provision of language services is so complex from a system of this type, where we're offering 11 million interpreter service minutes in over 180 languages, we've designated language access coordinators that handle the day-to-day administrative operations of language services.

They serve as our liaisons and provide additional support with cultural competency work. This structure helps us fulfill CLAS Standards 5 through 8, with respect to language services.

The second element is to have a firm understanding of our patient population in the surrounding community. Conducting a needs assessment will help you obtain a baseline to know who's walking through your door.

The data you routinely collect related to race, ethnicity, and language is important. The collection of real data and how accurately you collect this information will help you meet CLAS Standard 11.

Other ways to get a sense of your demographics include studying regional census data, analyzing data from your language service center, surveying frontline staff and supervisors, and interviewing local organizations to understand community needs. These steps can help you get a clear picture of who you serve and where your gaps are.

Equally important is how you use and apply the data collected, to stratify the data to identify health disparity so that you can develop intervention strategy. These efforts are aligned with CLAS Standard 12, as it relates to conducting regular assessments of community health, assets, and needs.

Health and Hospitals also has established community advisory boards that meet regularly to advise and provide important community input which helps us meet CLAS Standard 13.

Another element to consider is conducting an organizational assessment to understand your organization's present state in this journey. Assessment results will help define benchmarks on current performance in meeting health equity goals, and aid in developing benchmarking tools to measure progress.

And another factor to consider is engaging with stakeholders within your organization. What you want to do is to begin credibility and buy-in for this work at various levels within the hierarchy, so that you begin to frame this as a collective effort, and begin establishing accountability across the organization.

This process also brings value in understanding how this will impact organizational priority and goals. So it's important to speak with decision makers, implementers, and frontline staff to get their perspective.

Equally important is speaking to patients, learning from them what's working and where are areas that need improvement. The process will help inform you in how to embed this work into existing policies, practices, and processes.

With an accurate picture of who you serve in your organization's present state, you can begin creating the framework for how this body of work will fit within your organization. Listed are the areas of quality improvement that we focus on at Health and Hospitals. But I think these are kind of solid guidance for other organizations, big and small.

So looking at the list, we include governance and leadership structure to determine if and how leadership needs to be invested and engaged in this work, right? Because leadership and buy-in is so critically important to advancing this work.

Supporting the establishment of goals, policies, and management accountability, and infusing the standards in planning and operations is part of CLAS Standard number 9.

Data collection, and using and applying the data to help identify disparities, to meet CLAS Standard 11. Reviewing policies and practices, the development of internal communication strategies that inform staff.

Developing an external communication strategy that includes creation of easy-to-read multi-lingual patient education materials that support community engagement and health literacy efforts is required by CLAS Standard 8. Also strategies in how we communicate with the organization's progress and implementing CLAS to the general public as required by CLAS Standard 15.

And last but not least, the employee training and education, which is so critical in building capacity, sensitivity, and awareness; which is required by CLAS Standard number 4.

So if you look at your strategy from a process perspective. It can look like this, building awareness using a top-down, bottom-up approach, looking at the area of quality improvement previously mentioned to develop attainable and measurable solutions, and then how you execute those solutions and sustain them over time.

And make sure you develop a valuation and measurement tool to measure success by establishing clear goals, objectives, and activities that help you move that needle. So let me emphasize that the CLAS Standards are principles. And it's up to the healthcare organization to interpret and apply these principles to serve diverse populations.

For Health and Hospitals, there's an economic and business imperative in delivering culturally responsive care and language services, and thus we sought to operationalize the CLAS Standard because it's tied to safety, quality, and improving the patient experience.

Let me quickly walk you through the strategic planning process we conducted. We did a system-wide assessment to gauge our present state in the delivery of language services and culturally responsive care.

We wanted to understand current policies and processes, how language services were being developed, how our vendors were performing, how we were measuring performance, our state of compliance with legal and regulatory requirements, and what types of training was being offered to staff, to name a few areas.

In the winter of 2014, we brought together content experts that helped us to identify and discuss areas of focus that could help to improve the delivery of equitable care. The strategic planning process was informed by guiding principles in Health and Hospitals community needs assessment findings.

This resulted in identifying six critical areas for planning and quality improvement effort. And here they are.

These are the six quality improvement areas we focused on. And in May of 2015, we held a health equity symposium that brought together senior leaders and key stakeholders for a full-day strategic planning session around the six critical areas that support organizational change to enhance equitable care.

Each session was designed to guide participants through a facilitated conversation to identify measurable goals and outcomes, assist participant in developing approaches and solutions, and at the conclusion of the session, each working group had clearly articulated goals, supported by solution or action steps that informed development of the strategy to enhance equitable care by 2020.

The five priority domains and objectives were identified based on the review and consolidation of the recommendations from the working group.

Together they define Health and Hospital's approach toward improving equitable care, which align with Dr. Raju's 2020 vision, and the organization's guiding principles.

The symposium discussion resulted in the development of a white paper that outlines the three-to-five-year plan to enhance equitable care, which can be found in the upcoming health equity index resource guide issued by the Human Rights campaign.

And our health equity poster presentation is featured as a model that's practiced in the American Hospitals Association Quality of Equity toolkit.

I want to emphasize how Health and Hospital is unique in the fact that we have a diverse workforce. Our staff look like the patients that we serve. And we also have a diverse governance and leadership, as required by CLAS Standard number 3.

This is our Celebrate Diversity campaign, where volunteer staff participated in a photo slideshow and video presentation that provided a visual narrative, highlighting the breadth of diversity amongst (inaudible) New York City Health and Hospitals, and allow participants in their own words to share how they define and put into practice cultural competent, patient-centric care.

The photo slideshow and video presentation was launched during the Health Equity Symposium. And the collaterals were used for communication and education needs at facilities across the organization.

A video and photo exhibit was featured as in newsletters and presented now in external-facing in our House and Hospitals external website.

The concept behind this campaign was that when it comes to looks, we assume, we label, we judge; we generalize. But appearances and self-identity are not always parallel. Understanding someone's racial, ethnic, gender, and cultural identity, especially in the context of providing culturally responsive healthcare, takes more than a look or an educated guess. A face may tell part of the story.

Asking someone to self-identify their race or culture can fill in the blanks. And this is part of how we are informing staff, so that they can be better prepared to ask questions to better collect real data. But it also is integrating the concepts of unconscious bias into a learning opportunity by using this campaign.

21 of our Health and Hospitals facilities receive leaders in LGBT healthcare equality. Designated by the human rights campaign healthcare equity index. In March, we rolled out We are an Ally Campaign.

For an entire system to celebrate our designation, but also kind of message and prioritize the importance of having an inclusive and welcoming environment for our LGBTQ patients and staff.

This month we launched two new LGBTQ cultural competency e-learning modules, required for all staff. And we are currently exploring strategies for improving data collection for sexual orientation and gender identity within our system.

We also have issued gender-neutral bathroom signs that require all employees and members of the public using services, our services, to be allowed to use a single-sex facility within facilities that most closely align with their gender identity or expression, without being required to show identification, medical documentation or other forms of proof.

And so in celebration, in April we launched our first ever system-wide diversity celebration. The Celebrate Diversity photo exhibit was the purpose, and showcased across our 21 facilities. And at the same time facilities hosted cultural food expos and other events to celebrate staff diversity.

We also launched a social media campaign to showcase cultural responses provided across the system. And in conjunction, hosted interreligious workshops for many of our patient care centers, small-group facilitated dialogs with healthcare professionals on religious, cultural competency topics that support approaches to help direct care providers, address patients' religious beliefs,

respond appropriately and anticipate potential areas of conflict, thereby improving patient satisfaction and quality of care.

We also created a diversity and inclusion SharePoint site that houses the diversity and culture resource portal, a user-friendly, online database that offers healthcare professionals and other relevant frontline staff access to patient demographic information, best-practice approaches, and tools that can be used to provide culturally responsive care.

We also house in this portal essential document library, a repository of key patient documents available and accessible in English, the top 13 languages, and is also available in large print and in audio files to accommodate individuals with low-vision or who are blind.

And this is an example of the information found in the diversity and cultural resource portal. You have here kind of a facility-specific demographics Gouveneur, which is our long-term facility.

And it talks to you about the top foreign population language, the languages that are spoken within this facility. And then on the other side, you see Bengali, which is our third most requested language across our system.

And here you see photos from our Celebrate Diversity event across the system. So we had all our facilities really celebrate each other's diversity through food and music. And so this is a demonstration. And I would have you take note of the top photo from Kings County in Brooklyn, where you see this array of cultural diversity.

And they're holding a picture of Priscilla Swan, who self-identifies as queer. And so this is just a demonstration of how we at Health and Hospitals promote diversity within our institution. And of course here are other pictures, a few more for you to look at just to show how diverse Health and Hospitals is, and how we are reflective of the patients in which we serve.

And so the road ahead; you know, I said all this. And people must be wondering how much work we've done. But it's come with challenges. And to understand that this is, based on what Dr. Gracia said in the very beginning, this is a journey and it's not a destination. Slow and steady wins the race.

You've got to make sure to take manageable incremental steps that lead to a successful milestone or benchmark, having a goal in mind.

Because for every successful milestone, you will have a compound effect that helps build credibility and buy-in to move this work forward. Setbacks are inevitable, because learning actually begins when you actually start implementing.

So, don't be discouraged with this work. This work is hard. And just keep moving it forward, so having resiliency and perseverance for me has been key to moving a lot of this work. And so I thank you for allowing me this opportunity to share some of our experiences and insights, and happy to answer any questions at the end of all the presentations.

Wonderful. Thank you, Matilde, for that really comprehensive and thoughtful presentation. Our next presenter is James Williams. James will be presenting and providing an example CLAS adoption and implementation through an academic medical center.

James Williams, Jr. joined the University of Chicago Medicine in 1988 as part of the finance group serving in patient accounts, transplant and admission services, before transferring to supply chain in 1999.

In 2001, he helped launch the institution's first business diversity office building, building mutually beneficial business relationships with certified minority and women-owned firms. In October 2013, James was appointed as the initial director of diversity, inclusion and equity.

In this role, James is responsible for designing and implementing strategies to transform the University of Chicago Medicine to a more diverse, inclusive and culturally competent organization, delivering high-quality, equitable care to all patient populations. James, I'll turn it over to you.

Thank you very much. I appreciate the Office of Minority Health and Department of Health and Human Services for this opportunity to share a bit of our journey around CLAS at the University of Chicago Medicine.

So my objective today is really to share how we've been able to leverage the CLAS Standards and the blueprint in order create an enterprise-wide diversity and inclusion strategy, and accompanying governance structure, how it helps inform us in choosing strategic frameworks, how we've leveraged it do an organizational assessment, and then a subsequent strategy to advance CLAS throughout the organization, supporting us in building our cultural competence training strategy as a way to change culture.

Being integrated into the Pritzker School of Medicine education around health disparities. And lastly, how it helps us to infuse equity principles into our culture and key processes.

And so a bit of background about the University of Chicago Medicine; we're an academic medical center on the south side of Chicago. We're one of the largest employers on the south side of Chicago, with a strong focus on quality and equity and safety.

So that infrastructure allows us to link equity to quality, and some of the outcomes about our recent diversity and inclusion workshop was to earn leader status in LGBT healthcare. But we have a lot of work to do in that space to impact the entire organization.

The south side of Chicago, for those that are not familiar with it, the 15 zip codes around it are about 74% African American, about 12% Hispanic and Latino. 19% of the individuals in that area have less than a high-school diploma. About 29% live below the poverty level for a family of three. Medium household income ranges from $19,000. To $58,000. So the median actually is $35,000.

And the unemployment rate is about 21%. So you can get a flavor for where we are situated. And although we draw a lot of patients from our immediate area, we also draw patients from across the globe for quaternary and tertiary care that we specialize in.

So our journey began in 2013 when we created the institution's first integrated enterprise-wide diversity and inclusion strategy. We drew on the multidisciplinary expertise of over 85 members across the biological sciences division, Pritzker School of Medicine, and the medical center.

Our strategy has three core work streams that I'll share later. But it was flexible enough to allow each of those entities to choose an initial area of focus.

We intentionally embed CLAS principles of health equity, recruitment and development of a diverse workforce, and cultural competence training into this strategy, along the lines of CLAS standards 2, 3 and 4. And I'll share a little bit more about that later.

The core of this strategy is also linked to the institution, the University of Chicago Medicine's annual operating plan, where we have a people pillar, with two explicit objectives. The first objective is to build a culturally and linguistically competent organization.

And the second was to increase the awareness of diversity, inclusion, and equity objectives and imperatives at the middle manager level.

Here you see the three work streams and the high-level goals associated with those work streams. And you can obviously see the connections to the CLAS Standards. We look at all of our work to be in the service of equity, health equity for our patients, as well as extending to our community from a population health perspective.

We also look at equity in terms of how we engage and impact our colleagues across the organization. So those high-level goals are then broken down into three to five critical objectives. These objectives are collaboration starting points to engage and build action plans with functional leaders across the organization, who actually own the work.

Our diversity, inclusion, and equity strategy is to facilitate the integration of equity principles into the operational frameworks and processes of functional leaders and staff. We help them leverage equity to achieve their goals around the quality of care, improving the patient experience, and improving employee engagement.

One example that I can point out under the equity work stream, if you look in the far bottom right corner, it reads that we want to integrate quality indicators and methods into the UCM quality improvement processes to improve health outcomes and the patient experience.

So through our department's collaboration with clinical effectiveness or our center for quality, they now stratify all of our quality metrics by race, ethnicity, sex and payer. So essentially that stratification work which is one level of approaching equity, becomes their standard work.

Next, our next steps are to look at how to build and identify an infrastructure to analyze stratified data through the equity lens, and then begin designing practice changes, taking into consideration any social determinants of health revealed through the analysis.

From a CLAS perspective, this fits into CLAS Standards 10 and 11 around ongoing assessment, and collecting and maintaining reliable demographic data to monitor and evaluate impact on health equity.

Again, speaking to the CLAS governance theme, this is our multidisciplinary steering committee that provides governance for the enterprise's diversity and inclusion strategy. It is comprised of faculty, administration, and staff from the biological sciences division, the Pritzker School of Medicine, and the hospital.

CLAS 2 speaks to advancing and sustaining organizational governance and leadership that promotes CLAS. And so what you see here is me in the third box down. I serve at the pleasure of our President, Sharon O'Keefe, and our Vice President, Brenda Battle, for care delivery innovation, as Chief Diversity and Inclusion Officer.

So my department was created to provide the institutional resources to drive the strategy execution and the dedicated resources for cultural competence training, health literacy leadership, and equity integration across the organization.

To that end, we have a manager of education in training, Joel Jackson, and a program manager for health literacy, Lisa Sandos. What's not reflected in what you see here are two part-time internal resources. We have a nurse, Marina De Pablo, who supports our health literacy work.

And we also have Dr. Scott Cook, who is a health disparities expert, and Deputy Director of the Robert Wood Johnson Foundation funded, national program office of finding answers and solving disparities through payment and delivery system reform.

In fact, when you look at, in addition to the CLAS Standards being a guiding framework, another guiding framework that we've adopted to support advancing health equity is the roadmap to reduce disparities, which was produced by Dr. Scott Cook and Dr. Marshall Chin; Dr. Chin being the director of finding answers and solving disparities for payment and delivery system reform.

We are leveraging their six-step roadmap to train our organization on how to address any health disparities that we may find as we look at our stratified data through the equity lens. Right now our organization has linked quality to equity, and I'll share that a little bit later in step one.

We secured buy-in from a leadership perspective that you may have seen already. And we've begun our journey of creating a culture of equity. And I'll share another example of that later.

Building on a well-known patient-centered care model, we are now advancing throughout the organization the National Academy of Medicine, formerly the Institute of Medicine quality framework, which specifically calls out equity as a cross-cutting dimension of all components of quality care,

essentially acknowledging that you can't have patient-centered care if there are unfair differences in the outcomes and experiences between different patient populations.

And in the words of our Chief Quality Officer, inequitable care is low-quality care. Again, we see this as linked to the CLAS themes of engagement, continuous improvement, and accountability.

We engage functional leaders. We show them how equity can enhance their effectiveness, and use the equity lens to see gaps, redesign practice, and measure progress.

So switching gears from our guiding frameworks, I'd like to share another way we leverage the CLAS Standards and the blueprint in our work. Consistent with CLAS 10 around conducting organizational assessments, in the spring of 2014 our department conducted a comprehensive assessment to evaluate the current state of CLAS at the medical center.

We modified a validated cultural competence assessment tool from the Boston Public Health Commission, to reflect the enhanced CLAS Standards promulgated in 2013, and to capture diversity in the broad sense, including gender identity, sexual orientation, and other dimensions of diversity.

We used the resultant report to create a strategic map. This map was shared with a diversity and equity committee that's specifically focused on health equity to clarify goals, to identify functional responsibilities, and to build a cadence or a timing for the work as we advance it throughout the organization.

What we learned is that there's some critical elements to full implementation of the CLAS Standards. Consistent with CLAS Standard number 9 around infusing CLAS throughout the organization's planning and operations, and also with CLAS Standard number 15, regarding communicating the organization's progress; we see these steps as our next level of work.

So what we want to do is partner with quality, partner with patient experience, partner with population health and human resources, so that equity can be integrated into their operating framework strategies and initiatives, how they set goals, et cetera.

Two, we want to partner with marketing and communications to make sure that staff and community are in plain, accessible language, really see all of the efforts that we are driving toward advancing health equity.

And we want to foster the internal motivation of every staff member, so that they understand not only the impact of health equity on their well-being, but how they in their specific role can impact health equity.

So a quick example is when we're engaging in training registration staff, we can note that African Americans with diabetes have a higher rate of foot amputations than whites. We can ask them to think about their family and friends with diabetes, and what it might be like if we can use this data to find out if we are having similar disparities in our patients, and then taking steps to eliminate it.

We want to emphasize that they are the very first step in the important chain of events that will allow this to happen. Letting them realize internally that they are truly-- that they truly are a critical part of the care team that they play a role in patient care and health outcomes. They are not just there to do administrative work that's unrelated to care.

So stepping back a bit and looking at all of this, building on the diversity and inclusion strategy, and the guiding framework, our CLAS assessment and the strategy that emerged out of that; we launched a robust cultural competence training strategy to begin the culture change.

Aligned with CLAS Standard number 4, this strategy has four phases. We launched it in the fall of 2014. And while it's not required, it's open to everyone in the organization. And there has been robust participation.

The core of this is an 18-hour curriculum, supported by elements in our new employee orientation, and our ongoing departmental training. All of that work is guided by our office from a content and facilitator training perspective. And we are in the development of an online component.

So this interactive cultural competence course is designed to create change agents and serve as a foundation for those who want to co-facilitate and train in their departments. Graduates of the course gain skills, knowledge and insights to work more effectively in a multicultural setting.

Participants develop deep awareness and strengthen their listening, communication and collaboration skills critical to team building.

By design, the course is inclusive and transdisciplinary with physicians and researchers and clinical staff and environmental services all learning together how to make a difference every day for our patients and staff through cultural and linguistic competence.

We connect this to quality, safety, patient experience and employee engagement. We consider all elements of diversity. We address power and privilege, unconscious bias, and how these impact service provision and the patient's healthcare experience.

We help people learn how to build trust across difference, meet the communication and language needs of persons, build skills to resolve world view and ethical conflicts. We identify health disparities at the local and national level, and how each person can be an equity change agent in their particular role, at the individual personal level, the team level, or the organizational and community level.

To date, our cultural competence training strategy has delivered over 8,000 hours of training, reaching approximately 2,800 individuals, including 184 graduates of this full 18-hour curriculum in over 100 areas across the organization.

Aligned with CLAS Standard number 8, to provide easy-to-understand materials, we aim to be a health literate organization, based on the IOM model of 10 attributes of a health literate organization.

You can see the documents we've translated into plain language, and the number of departments we've touched. We've also integrated health literacy principles into an emerging enterprise-wide patient education strategy. And lastly, we developed a tool for institutional use on how to create and revise materials in plain language.

Continuing around the education and training vein, and then coupled with the CLAS theme of communication and language assistance, Dr. Monica Vela, who was our associate dean of multicultural affairs at the Pritzker School of Medicine, and associate vice chair for diversity in the Department of Medicine, developed and leads the health disparities equity and advocacy course for Pritzker students.

One module of that course is focused on the care of limited English proficient patients. This topic is also extended into the Pritzker's clinical skills course, which she co-directs.

The course provides skills on how to use an interpreter. And it also is designed to help providers and students understand that unless you have been tested proficient per CLAS Standard requirements, you should not be providing care without interpreter services.

This course emphasizes the language concordant-- that language concordant care is a quality issue as well as an equity issue. Further linking cultural and linguistic competence to quality and equity.

CLAS 9 speaks about policies. And on the policy front, we've integrated culturally competent language into all of these policies. Our visitor access, our patient rights and responsibilities, and equal employment opportunity policies specifically call out that we do not discriminate against persons based on sexual orientation and gender identity. And we've paired that with training around care in health services for LGBT persons.

Our patient education policy calls out plain language explicitly. We have a primer on plain language and how to utilize teach back (ph). And to support updating policies across the institution, we've developed guidelines to assess policies for CLAS that's available on our intranet.

This image represents our most recent work to build and integrated model for how we aim to improve the quality of care, the patient experience, and employee engagement. In the blue center is E3 leadership. That is our enterprise-wide lean management system for how we engage, evolve, and excel as an organization.

Also in the blue center is the principle of equity, which is to be integrated into E3 leadership and all of the other functional frameworks and processes represented by the other five circles.

Those five interconnected circles represent an initial sharing of knowledge between all of these areas, and ultimately the sharing of skills with each other, remaining true to our core of E3 leadership and the equity principle. To arrive at this place, the diversity, inclusion, and equity department convened a half-day leadership retreat to improve health equity.

That included an introduction to the roadmap to reduce disparities. It also included working through a case study, and a SWOT analysis; strengths, weaknesses, opportunities, and threats; analysis around how equity can enhance the work of each area.

The initial examples of what equity looks like in practice for these areas are clinical effectiveness or quality, stratifying quality data by patient demographics, patient experience, integrating equity-focused questions into survey instruments, and human resources, stratifying workforce and employee engagement data by employee demographics.

. And even our department, diversity, inclusion, and equity; integrating E3 leadership lean tools into our work, and facilitating equity integration into operational frameworks of others.

And so our challenges and our successes, challenges, and lessons learned are that the successes were integrating CLAS into our annual operating plan. And then building the robust governance structure and having dedicated resources focused on equity.

From a challenge perspective, we're challenged like most other academic medical centers, that value-based reimbursement requires care delivery transformation so that large-scale, complex organizational change, which is a severe drain on resources, which is why integration is so key, so that it becomes integrated, and not an add-on.

And lastly, the resources to meet the training and health literacy demand, so our lessons are link quality to equity, infuse it into everything that you do from a culture and process perspective. And then plan, execute in an inclusive values and data-driven manner.

I thank you for your time.

Thank you very much, James, for that excellent presentation. We will now move to our final presenter, Katie Meehan, who will represent an example of CLAS adoption and implementation in a public health department.

Many of you know that we underwent an enhancement initiative to enhance the National CLAS Standards. The Standards were first released in 2000. We underwent an enhancement initiative from 2000 and 2013, and released new and enhanced National CLAS Standards.

And as a key part of that enhancement, was a more explicit calling out of the role of public health. This was not only relevant and applicable to healthcare, but also to public health more broadly.

And we've long had public health partners who have been supporting and adopting and implementing the National CLAS Standards. But this also provided even greater reinforcement to the important role that public health has to play in advancing CLAS. So we're very pleased to have Katie join us this afternoon.

She is a community relations and equity consultant at the Washington State Department of Health Center for public affairs. She received her Bachelor of Science in community health from Western Washington University, her Master of Public Health in Health Services from the University of Washington, and is a certified health education specialist. She has worked in community, state and international public health.

And her work includes providing consultation to programs on implementing the National CLAS Standards, and advancing health equity, engaging communities that are experiencing health disparities, and addressing structural inequities within the Department of Health.

Katie, I'll turn it over to you.

Great. Thank you for the introduction, and thank you for the opportunity to present today. So I'm covering kind of three objectives during my presentation. First is how CLAS work has evolved at our public health agency; secondly, our approach to adopting and implementing the CLAS Standards; and third, some lessons we've learned along the way.

So I'd like to begin by sharing our agency's structure. Our department has about 1,700 employees. And there are 33 different offices within our department that vary significantly in the type of work they do, and the customers they serve.

Because the work of our offices and the people they serve are so diverse, the CLAS Standards that are most relevant for one office may not be as relevant for another.

And I'm going to give you a few examples of the type of work you can find around our agency, and how CLAS might ideally guide their work. So, on the far left here, we have our state health officer, or state health office.

And among many of their responsibilities, some of their key responsibilities are to coordinate all of our state-level assessments through surveys like the Healthy Youth survey, or the behavior risk for factor surveillance system.

And so this work falls under CLAS Standard 11, which is about collecting and maintaining accurate and reliable demographic data. And they're constantly looking at whether or not we have sufficient representation of the different ethnic groups that are emerging in our state, to be able to collect data over time, and really look at how health disparities may change for some of our smaller populations.

Next over here, we have our public health operations. And in this area of our agency exists all of the divisions, offices, and programs that basically provide most of our external-facing services.

So you'll find work like programs who respond to emergencies like wild fires, our programs that test the safety of our shellfish and drinking water, our direct health education programs; whether it's marijuana prevention or chronic disease or diabetes; and then also our work around licensing healthcare professionals and regulating healthcare facilities.

I'd say that the bulk of our CLAS Standards work currently exists in this area. And all of their work touches on all of the different CLAS Standards. So this is when we look at the health education materials we have out there that are available in multiple languages, or programs who are using alternative communication methods, like video and audio; this is where we'll find a lot of that work.

Next over is our administrative operations area. And the offices in this area are those who are internally-facing. So their customer base are actual Department of Health employees and programs.

They have a large variety of responsibilities as well. And they vary from leading our agency's recruitment and hiring efforts, so in our office of human resources; helping programs with their contracting grant processes in our office of financial services; and also helping all the internal programs with their internal technology needs.

And then our last area over here is the center for public affairs. And this is a new office within our department, which is at the agency level. It supports high-priority projects and initiatives for our agency.

And we also serve as consultants to the rest of the agency. And this is where our CLAS and health equity work currently lives.

Now that I've shared an overview of our agency, I'd like to walk you through the years of work and efforts that have brought us to the point where we are today. I would say that overall our agency's efforts related to equity and CLAS have been a trial-by-error approach.

Just as many of the earlier presenters have mentioned that CLAS work is really a journey. And for us it's been a journey of a few decades.

We've learned a lot along the way, and I'd say that all of our past efforts have definitely contributed to where we are today. So I'm going to highlight some different key dates in blue, as I move through our timeline.

You'll see the first set of activities that I've highlighted really have to do with trying to improve the cultural competence of our workforce through training and learning opportunities.

There's been a lot of effort to do this over the years, and that it has contributed. But as a result, we've learned that training is great. But it doesn't get us to the system-wide change that we really need.

In 2006, we had our first push for the formal adoption and implementation of the CLAS Standards specifically. There is a work group that was created, looking at more specifically language access and translation and interpretation needs of our customers. And they put forward a pretty comprehensive set of recommendations that were built on the CLAS Standards and the CLAS Standards blueprint.

And it did stir some interest and support. But unfortunately we didn't have the leadership backing at that time to really bring those recommendations into fruition.

Also in 2006, our governor created an interagency council on health disparities. And this council includes representation from many state agencies, including our Department of Health. In 2013, this council received a grant from the Office of Minority Health through our closely affiliated State Board of Health.

And we partnered with them to develop a variety of CLAS training materials and opportunities, which I'll highlight a little bit later on.

Also in 2013 our department received its PHAB accreditation. And previous efforts related to CLAS, equity, and cultural competency helped us in our ability to achieve this accreditation, and will help us in our next reaccreditation process. PHAB requires that we provide examples of health materials that illustrate that they were designed for a culturally diverse audience in multiple languages that we took health literacy needs into account.

And with the update of the PHAB Standards, this emphasis on culturally appropriate services has even been stronger and more emphasized. So for all public health agencies seeking accreditation or reaccreditation, CLAS Standards really help with some of those requirements.

And so in the last two to three years, I'd say this is kind of where our work has sped up. A lot has happened that really increased our agency's readiness to adopt and implement CLAS. In 2013, we got a new secretary of health, who is committed to health equity. And within his first year, he launched a cross-agency health equity work group that has support from our executive team.

He also led a strategic planning process that resulted in adding health equity as a guiding principle in our strategic plan. And what this did was set an understanding across the agency that not only health equity was considered important by our leadership, but that's there's an expectation to really infuse it and its principles throughout all of the work that we do.

Along with the various activities that the health equity work group took on, they also advocated for the development and centralizing of two positions. One position to provide some leadership around health equity efforts, and one position to lead the adoption and implementation of the CLAS Standards. This is how the position I currently hold was established.

And then late last summer a new entity was created at our agency called the diversity and inclusion council. And this council replaces our previous reiterations of division and agency-wide multicultural work groups.

And the council was created with executive team representation and leadership through our department of human resources, to really give us the ability to push policy change forward.

And the last milestone we have on our timeline was the launch of our agency center for public affairs. So this new center has four quadrants of work: policy development, strategic communications, government relations, and community relations and equity.

And it's that last quadrant, community relations and equity, where our agency has allocated centralized resources to advance health equity and implement CLAS.

So, just as the type of work is very diverse with the department, so is our customer base. So as a state department of health, we serve the entire state of Washington. And there's a lot of cultural and linguistic diversity across our state.

So about half a million people in Washington State have limited English proficiency. And this is especially true for our residents who were born in another country.

Overall, there are 200 different languages spoken in our state, with the top six languages being Spanish, Russian, Vietnamese, Ukrainian, Korean, and Somali. Other residents in Washington who have limited English proficiency, about 4% live in linguistic isolation, which the census defines as being no one in that household over the age of 14 years old speaks English very well.

So what this basically means is that that household doesn't have access to someone who speaks English well enough to help other members of the household navigate important resources and services.

We also have the most ethnically diverse zip codes in the entire country in some of the neighborhoods within our Seattle and metropolitan area. And we have 29 federally recognized tribes, and are also a large refugee resettlement state, with our largest recent populations coming from Iraq, Somalia, Burma, Ukraine, and the Democratic Republic of the Congo.

So there are many more aspects of cultural diversity that we experience that aren't on this slide. And it is something that we're-- as we move forward with our CLAS work that we're trying to work more under the expanded definition of culture, which is available in the CLAS Standards blueprint, which includes things like age, sexual orientation, immigration status, military status, and physical and cognitive ability.

We have eight steps in our current approach to adopting and implementing CLAS. All of the ones that have a checkmark, we've completed. And the two that are bolded are where we are at now.

So we completed a brief organizational assessment, and looked at other efforts, both internal and external that we can align our work with; developed some training and resources for staff. And we're currently working in this area here.

So over the next few slides, I'll walk you through what we've learned on the pieces of our approach that we've completed, and where we're heading right now.

So first, we have our organizational assessment. There are a few different pieces that made up this assessment. We did an all-staff survey about health equity and CLAS and had a 42% response rate.

Our main finding from that survey was that a lot of staff had difficulty explaining how health equity guides their current work, and that basic understanding of the social determinants of health was quite low, especially in certain areas of our agency.

And we also did key informant interviews with 13 of our agency leaders. And we used the Department of Justice's language access assessment tool to kind of look at where some of our gaps are in language access. One of the biggest takeaways we had from our assessment is that it really is something that needs to be done at our office level.

As I said before, we have 33 different offices, and trying to do this assessment sitting up from the agency seat, didn't allow us to really see what's going on and what needs to be done within all of the different programs.

So if you take an example of translated materials, we have programs that systematically translate all of their materials into the top nine or even 13 languages, like our WIC program, which is shown up above here, or some of our other chronic disease prevention programs shown below.

But then we have others that are struggling to put even their most vital information and communications or notices into Spanish. So there's a pretty large variance across our agency.

On the left-hand side, I've included just a few of the questions that we asked during our key informant interviews with leaders. So we asked them to answer these question on a scale from 1 to 5, with 1 being not at all.

And these are the averages of their responses. So what was interesting for us is that we saw that leaders were more likely to think that the programs and offices that were under them or under their leadership are doing a better job at meeting the CLAS Standards than the agency is overall.

Another key thing we learned from our assessment was the need to align our CLAS efforts with other related efforts. Those of us who work in health equity or implementing the CLAS standards, we understand how all of these pieces fit together. However, to many staff around our agency, these look like isolated efforts or a new thing, or a new initiative.

So one of our greatest achievements was getting CLAS incorporated into the health equity cross-agency work groups' strategies. So it fits in multiple, but it's specifically called out in this infrastructure strategy, which is pictured on the far left.

We also have our diversity and inclusion council, whose work really focuses on CLAS Standards 2 through 4. And we're partnering with other external efforts, just to make sure that we're not duplicating, and benefitting from the work that's already occurred.

So the next step in our process was the development of training opportunities. And the need for CLAS training came out clear in our key informant interviews with leaders. So these are snapshots of the four e-learning modules we were able to develop in partnership with our governor's interagency council on health disparities.

The first module covers an overview of key terms. It helps learners differentiate between equality and equity. And it goes over the principle standards. And the next three modules focus each on one of the themes of the CLAS Standards.

And so since the training materials were intended to help provide staff with a foundation in the CLAS Standards, we also developed an internal website of resources to help them actually move from general understanding to implementation. So the goal we have here is to have a one-stop shop.

So for example, we have some basic language, race, and ethnicity data for the state. And we're currently working to provide this information at the county level, and to go beyond race and ethnicity in language, as I mentioned earlier, and incorporate other aspects of culture.

So our hope is if a program needs to send out a communication or a notice to a certain county in our state, they'll be able to come to this site, and look up at that county, and get a snapshot of the different cultural and language factors that they should be taking into account.

The second image here is a snapshot of our implementation tools and resources page. And this page is arranged by standard on purpose. We're hoping that as staff come to this website to get the tools that they need, that it also helps them connect their work and how it relates to the CLAS Standards.

So this brings us to where we are now. Now that we have a lot of tools and resources developed or are currently in the works, we're at a place of trying to truly adopt and implement CLAS at a policy and systems level.

So our first plan was to actually start with the policy, and what we learned through that approach was that instead of starting at the policy level, creating an umbrella policy for the entire agency, we really needed to take a step back work with offices individually.

So we are currently working on CLAS plans, and between July and October we will be piloting CLAS planning workshops with 11 of our 33 offices. And the goal of these workshops are for all of the staff to understand how CLAS relates to their work, and for the offices to identify one to three CLAS goals that they will work on in 2017.

And so as offices participate in and leave this workshop, they will also leave with a class plan that's going to put them in compliance with that future agency policy.

And the eight components you see here are the eight components that will be included in the CLAS plans. We'll also be touching on hiring and recruiting, since all programs have a role in making sure that we have an agency that reflects the diversity of the state that we serve.

And just to give you an example, we're letting offices really choose what goals they want to take on for the next year. And it could be something, for example, for translation services. An office could decide to plan to translate their top 10 vital documents into the top five languages in our state over the course of the next year.

I know we'll have some more lessons as we continue this work. But here are some of the lessons that we've learned so far. So first, leadership support is really important. Our CLAS work really didn't get momentum until we had this new wave of leadership that is committed to health equity, and included their commitment in our strategic plan.

Second, dedicated staffing really helps move this work. We now have CLAS and equity positions at our agency level. And this really gives us a backbone to fall back on. Third, to embed CLAS as part of a larger effort, so CLAS is really a framework to advance health equity and reduce health disparities. And using this larger frame helps our staff understand how our various related efforts really all fit together.

Fourth, engage programs and staff already integrating CLAS into their work. So this is a recent lesson for us. You know, we tried to start with that agency-wide umbrella policy approach. And we got a mix of resistance and excitement. So we're revising our strategy and starting this work with the willing first.

And so we already have one third of our offices that have signed on to voluntarily work with us on their CLAS plans. And we're hoping that this kind of garner up the momentum needed to get the second two thirds onboard.

Fifth is to tailor your class approach to the office's scope of work. You know, we have a lot of programs that don't necessarily receive federal funds. But they're fee-based, or receive state money. But they still need to comply with CLAS, because our agency does. And resources are definitely a constraint for them.

So helping our programs look for small wins or low-hanging fruit so that they can be part of our journey with CLAS, but also within the resources that they have.

Another piece to this is those of us who work in CLAS and equity sometimes want to share everything about the CLAS Standards, or want all of our staff to fully understand the whole framework. And what we're finding is that what we really need is for staff to understand how it relates to their work. And maybe that's just a few of the standards that we focus on.

And that kind of dovetails into remembering that this is an ongoing journey, and a continuous improvement process. And last, CLAS and equity work isn't achieved through a one-time conversation. So when we think of the systems that we have in place that are driving disparities in health or providing services that don't meet cultural and linguistic needs, these systems took a long to build.

And they're going to take a long time to unravel and improve. So with that, thank you for the opportunity to present. I have a few links here for more information, or please feel free to contact me directly with any questions or comments.

Thank you so much to all of our presenters and your really great information. We're looking forward to being able to share this information further with those that are on the webinar.

With that said, we're going to go ahead and answer a number of questions. We have received many really great questions. And so for the purposes of maintaining time as much as possible, we are only going to have time for a few questions.

So for those of you that still have additional questions and we don't get to them, please feel free to send your questions to AdvancingCLAS; that is C-L-A-S, at ThinkCulturalHealth.hhs.gov. Again, AdvancingCLAS, C-L-A-S, at ThinkCulturalHealth.hhs.gov.

And one other announcement; we've received several questions regarding whether this webinar presentation and the audio file will be available. It will be available at ThinkCulturalHealth.hhs.gov, within the next week. So please stay tuned. We'll send out an announcement letting people know that it is available. Or you may also visit ThinkCulturalHealth.hhs.gov.

Okay. So let's go ahead and take a handful of questions. The first one is for Dr. Gracia. But this is also open to other panelists. The question is, what trainings are available for health professionals on CLAS?

Thank you, Lili, for that question. We do host a platform of e-learning programs, continuing education programs that are available on the ThinkCulturalHealth website that Lili has been mentioning, which is ThinkCulturalHealth.hhs.gov. Our e-learnings programs, one for physicians that is actually accredited for physicians, physician assistants and nurse practitioners.

There is also an e-learning program for nurses that is accredited for nurses and social workers. There is a disaster preparedness and crisis response curriculum that actually services for many first-responders, as well as an oral health professional e-learning program. And that program is accredited for dentists, dental hygienists, and dental assistants.

And we also have of our latest suite of e-learning programs is a program specific for Promotores de Salud, commonly known as community health workers or lay health workers that work in Latino communities.

And the important thing to know is that all of these e-learning programs are free. They are available on our website. And as I mentioned for the ones that are accredited, the physicians, nurses, disaster preparedness and crisis response, and oral health professionals; those are accredited programs so that health professionals can also get continuing education credits in taking those programs.

Thank you, Dr. Gracia. The next question goes to Matilde from the New York City Health and Hospitals. What are some of your CLAS performance indicators?

That's a great question. So for me, the performance indicators, the simple one would be the language services that we provide. So looking at performance indicators, looking at connectivity and wait times in order to connect with an interpreter, the quality of the interpretation services rendered, eliciting feedback from not only patients but providers about what their experience was with how the interaction and that engagement or that language encounter happened.

It's kind of looking at it from the language services. And when you look at other performance indicators, and looking at how many trainings, that's an output. The greater challenge for us is to figure out how does the trainings that we offer affect change in behavior. And change, to really lend itself to understanding, is the trainings that we are offering is actually conducive to people adhering to the standards, in how to provide culturally responsive care.

And so that we're still-- we're still baking that, and trying to figure out what are those mechanisms. We could say that for physicians, for example, in documenting the interpreter encounter with a patient. Are they documenting it in the database system? And what's the frequency of the documentation, and how accurate is that documentation?

So for example, for a limited English proficient individual who has an encounter and comes regularly to Health and Hospitals for care, looking at those encounters and seeing if there are gaps in the documentation by that provider.

That allows us to really understand if in the continuum of care they are actually providing interpretation services at that point, or speaking directly in their target language, if the bilingual commission has the competencies to communicate directly with that patient in that target language.

And so those are some of the performance indicators that we look at to look at quality, and look at pretty much what we're looking at is the quality of the interpretation services.

Thank you so much for that answer, Matilde. James, I'm going to go ahead and move onto you. We've had several questions regarding the certifications that you require for your interpreters and translators as part of some of the work that you were demonstrating in your presentation. Could you speak to some of those pieces?

Yes. I don't have the names of the certifications that our manager for interpreter services uses for interpreters, and the ones that they also require of the firms that do the translation of documents, written documents. But I did send a note to them to get that. So if people want to reach out to me directly, I'm happy to share that feedback that information that I get from my colleague who manages that team.

Thank you, James. And we'll make sure to send a follow-up email to everyone that's on this webinar with contact information from the panelists so that those questions are directed to James.

Katie, I'm going to turn over to you. We know that there are challenges getting folks to answer the race question, and especially once they answer the ethnicity question. So do you have any particular tips or strategies on how to make people understand that they are two different questions? And then encourage them to respond to both.

I think a lot that probably just has to do with the format of the survey. And I'd have to talk with our state health office to see if we've observed the same trend in Washington State. If the person who asked this question wants to send me an email as a follow-up, I'd be happy to follow up on that. But I think in general, a lot just has to do with format to ensure folks answer both.

Thank you so much for that Katie. And I see we have about two more minutes, and we have a little bit more information to share with you regarding resources. So we're going to end the question-and-answer period there. However, just note that there are opportunities for you to continue to submit your questions to us at AdvancingCLAS@ThinkCulturalHealth.hhs.gov.

I'm going to turn it back over to Dr. Gracia to share a couple more resources, and we will go from there.

Great. Thank you, Lili. And thanks for all of the wonderful questions that we've been receiving. And thanks again to our presenters. So you heard actually some of our presenters mention a blueprint, the CLAS blueprint. This is also available on the ThinkCulturalHealth website that is managed by the Office of Minority Health.

This website has not only the National CLAS Standards, but a blueprint which provides information on each of the 15 standard strategies for implantation, models of practice, as well as a resource bibliography. It's available, again, at no cost to you. So use this as a template and a framework for implanting the National CLAS Standards. So I encourage you to utilize the blueprint.

The next slide will show you the actual ThinkCulturalHealth website. Again, that's available at ThinkCulturalHealth.hhs.gov. As you can see on the website, there's information on the continuing education programs, to our e-learning programs. There are other materials, not only the CLAS Standards and the blueprint, but also language guides and other materials and literature that's available.

And you can also send in questions and certainly also join the CLCCHC, as we call it, which is join the Center for Linguistic and Cultural Competence in Health Care, to get our quarterly newsletters and other information.

On the next slide, this is a resource as well, in particular for state-level action. Just last month we released the first ever compendium of state efforts on implementing the National CLAS Standards, state-sponsored implementation activity. So that compendium is also available to you for free on our website.

It in particular highlights what's happening through various state public health departments with regards to their activities in implementing the National CLAS Standards and other cultural competency efforts.

On the right side of the screen, what you'll see is our tracking CLAS map. This is a map where you can actually-- it's an interactive map. And you can actually see what's happening within your state. It's a dynamic effort.

And we will continue to update the information with regards to legislation that may be passed to training requirements that may exist within your state or territory, and other information, other services that are being provided within the state.

So I encourage you to join us for our next webinar. We will have a third webinar that will be on implementing the National CLAS Standards. You can stay tuned for more information and invitations for that webinar. If you receive an email invitation to today's webinar, you'll receive an invitation for the upcoming webinars.

But if you're not on our LISTSERV (ph), we do encourage you to please sign up for our LISTSERV, so that you can get this information, which is on our next slide, the Office of Minority Health website, which is MinorityHealth.hhs.gov. You can sign up for our newsletters, our email updates, and then we have the ThinkCulturalHealth e-newsletter available at ThinkCulturalHealth.hhs.gov, and to be able to sign up for that quarterly e-newsletter.

And as Lili has been mentioning, where you can get more information and where you can send in further questions to us, and we look forward to continuing this journey with you. Those of you that have been on this journey, and those of you who are new to the journey, as it relates to CLAS and the journey toward health equity, this has really been a great conversation and dialog. And we really appreciate you joining us for today's webinar.

And as was stated, we will have this information available on our website within the coming weeks. So please do stay tuned, and email us if you have any questions. Thanks, everyone. And this ends and concludes our webinar for today.