Hawaii Region Diversity Strategic Plan 2012

Transcription

1 Hawaii Region Diversity Strategic Plan 2012 Mission The Diversity Council supports the staff and physicians of Kaiser Permanente Hawaii to improve the health of our members and the communities we serve and the organization s commitment to eliminate health disparities. The Diversity Council shall plan, develop, coordinate, implement, evaluate, and improve the Diversity Work Plan. This Work Plan focuses on the refreshed Diversity strategy. 1. CARE: Provide the best care and service for all populations to eliminate disparities and create equity in our communities. 2. WORKFORCE: Optimize diversity at every level and create inclusive environments. 3. MARKETPLACE: Provide the most compelling value for our diverse populations and communities. 4. SUPPLIES DIVERSITY / COMMUNITY: Build equity through businesses and jobs and promote diverse and thriving communities. Our Mission supports the Hawaii region Strategic Initiatives of Quality, Service, Growth, and People as we seek to become the leader in clinical excellence and patient safety. Cultural Competency Plan The Hawaii Region Diversity Council provides oversight to ensure that all members receive care that is culturally sensitive and provided within the context of their individual or cultural group. Current programs, data needs and priorities align with the National Culturally and Linguistically Appropriate Services (CLAS) Standards developed by the Office of Minority Health (OMH). The 14 standards are organized by themes: Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational Supports for Cultural Competence (Standards 8-14). Within this framework, there are three types of standards of varying stringency: mandates, guidelines, and recommendations as follows: CLAS mandates are current Federal requirements for all recipients of Federal funds (Standards 4, 5, 6, and 7). CLAS guidelines are activities recommended by OMH for adoption as mandates by Federal, State, and national accrediting agencies (Standards 1, 2, 3, 8, 9, 10, 11, 12 and 13). CLAS recommendations are suggested by OMH for voluntary adoption by health care organizations (Standard 14). 1

2 Standard 1 (guideline) Culturally Competent Care ensure that patients/consumers receive from all staff member s effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. Strat Map: Service Worked with Regional Learning Council to incorporate diversity and cultural sensitivity training into the annual regional mandatory training requirements. (Angela 6/11) Physician training and classes for providers and caregivers include caring for patients of different cultures. Inclusion of EEO, Affirmative Action, and Diversity in the Regional New Hire Orientation and Physician Orientation. Inclusion of Culturally Competent Care module in the Regional Clinical Orientation for nursing staff who work in the hospital. This training is offered twice monthly by the Clinical Competency Department. Inclusion of Cultural Diversity topic in the Leadership and Supervisory Training Program provided by Learning and Development, Human Resources. Health Plan annual revision of the member handbook which has a section on interpretive services, written in various languages. Patient rights and responsibilities document stating the patient s rights to receive culturally competent care, including language assistance. Members receive information annually in Member Handbook and Partners in Health magazine. Hospital patients receive a copy as part of their admission packet from Admitting. Additions of diversity resources and documents in the online Clinical Library Providing Culturally Competent Care website accessible to all staff and physicians. Annual review & alignment of Diversity training content across disciplines (Gary, Teresa, Leanne, Cindy, Dana 7/12) Review Diversity & Health Video Series and Provider Manuals (Dr. Bell, Dr. Tim-Sing, Leanne Kauwe 7/12) Feasibility study of Quality Interactions elearning presented at 2011 National Diversity Conference, offered by Massachusetts General Hospital Dr. Joseph Bettencourt, and incorporate in new staff and MD hire orientation (Dr. Bell, Dr. Tim-Sing, Leanne, Cindy) 2

3 Standard 2 (guideline) Staff Diversity implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area Developed strategies and tactics to promote diversity in aspects of recruitment and workforce planning. (Angela, Kristen, 11/11) o Recruitment Services worked with Waipahu High School to set up guest speakers to inform them about the health care industry and possible volunteer opportunities with KP o Recruitment Services set up a few non-clinical internships with current college students, drawing respondents from various local business colleges and local universities as well as alumni of Kamehameha schools. An Affirmative Action Program is prepared annually to monitor representation and advancement of women and minorities in the KP-Hawaii workforce. Hiring goals are set when representation is significantly lower than availability in the community from which we recruit and hire. Hiring, promotion, and termination rates are monitored, and recruitment and outreach are targeted at minorities, women, disabled, and veterans as required by Executive Order and statute. Non-discrimination and non-harassment policies are currently enforced and are accessible to employees on the KP intranet. A reaffirmation of commitment to the EEO philosophy and practice is published by top management and posted al all KP facilities and distributed to employees and physicians. A similar statement by Kaiser s national CEO is also posted and distributed. During orientation, new physicians receive a binder with various EEO related policies and documents and sign a statement that they have reviewed the materials. Apply learnings from 2011 nonclinical internship program and further develop the program (Gary 8/12) Develop Veterans Hiring Toolkit to support America s Hero s At Work initiative (Gary 8/12). Strat Map: Quality, People 3

4 Standard 3 (guideline) Staff Education and Training ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. Clinical Library upgraded Create folder called Culturally Competent Care to hold all diversity resources in one place (Kristy, Cindy, Joann 9/11) Inclusion of EEO, Affirmative Action, and Diversity in the Regional New Hire Orientation and Physician Orientation. Inclusion of Culturally Competent Care module in the Regional Clinical Orientation for nursing staff who work in the hospital. This training is offered twice monthly by the Clinical Competency Department. Inclusion of Cultural Diversity topic in the Leadership and Supervisory Training Program run by Learning and Development, Human Resources. Annual communication to all staff regarding the online Clinical Library Providing Culturally Competent Care website, which includes links to the Interpretive Services Program Guidelines, Diversity resources, Providing Language Assistance Policy, Language Bank, translated documents, and external sites that offer multi-language patient materials. Continue with current initiatives to provide ongoing training and education for staff on culturally and linguistically appropriate care Annual review & alignment of Diversity training content across disciplines (Gary, Teresa, Leanne, Cindy, Dana 7/12) Review Diversity & Health Video Series and Provider Manuals (Dr. Bell, Dr. Tim-Sing, Leanne Kauwe 7/12) Feasibility study of Quality Interactions elearning presented at 2011 National Diversity Conference, offered by Massachusetts General Hospital Dr. Joseph Bettencourt, and incorporate in new staff and MD hire orientation (Dr. Bell, Dr. Tim-Sing, Leanne, Cindy) Annual review / revision of RCO training (Teresa, Dana, Cindy) Strat Map: Service, People 4

5 Standard 4 (mandate) Qualified Language Assistance Service Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. Dual hand-set phones for Language Line telephone interpreting installed and implemented in E.R. Registration and Admitting (Joann, Cindy 8/11) Implemented use of Pocket Talkers sound amplifiers clinics and hospital (ADA Committee, Erwin Soria, Joann, Cindy 5/11) Annual maintenance of an online language bank of bilingual and multilingual staff and physicians and languages spoken. Link: Intranet Home Page click on Links Type in Language Bank in the Search field Ongoing update of physician biography cards and online medical staff directory to include languages spoken. Maintenance of online Clinical Library Providing Culturally Competent Care website, which includes links to Diversity resources, policy, language bank, translated documents, and outside sites that offer multi-language patient materials. Ongoing review and update of Interpretive Services Guideline which includes step-bystep instructions for requesting an interpreter and contracted vendor listing including inperson interpreter vendors, telephone interpreter vendors, American sign language referral agency, services for the blind, and information on hearing and speech impaired phone devices, lip reading, captioners, and notetakers. Initial assessment to improve interpreter services in the neighbor island clinics (Joann 10/12) Revise online Language bank of bilingual staff website intro message (Joann, Albert Mossman 5/12) Continue to explore video interpreting for hospital (Joann, Cindy, IT 10/12) Develop Alternate Format process (Braille, Large Print, Media) (Gayle, Joann 2/12) Explore funding options to obtain dual hand-set cordless phones for hospital 250 beds, 7 floors (Cindy, Joann 7/12) Develop and implement KPHC interpreter scheduling form (Joann, Cindy Akau, Chris Peters, Sylvette Akana 8/12) Strat Map: Service Explore kp.org and regional waiting room videos as venues for providing members with culturally competent information e.g. rights to language services how to become active participants in their health, Ask Me 3 (Gayle, Cindy, Joann 10/12) 5

6 Standard 5 (mandate) Notices of Patient Rights to Language Assistance Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. See annual / on-going activities column Annual revision of the member handbook, which has a section on interpretive services in various languages (English, Chinese, Spanish, Hawaiian, Ilocano, Japanese, Korean, Samoan, Tagalog, and Vietnamese). Availability of Language and Hearing- Impaired Services member brochure in various languages in the hospital and clinics (English, Chinese, Ilocano, Japanese, Korean, Tagalog, Vietnamese, Hawaiian, and Spanish). Principles of responsibility / Member & Patient Diversity statement: Our aim is to deliver health care that acknowledges and understands cultural diversity in health beliefs, practices, and communication. In order to meet these goals, we must consider and respect members and patients cultural needs when we are involved in their care or have contact with them or their families. Annual General Compliance Training inclusion of Diversity information to increase staff awareness of the National Diversity website and agenda, and Interpretive Services Program. Staff awareness increases verbal offers informing patients of their right to receive language assistance services (Angela, Regional Learning Council Contact National Facility Services for status of federal requirement to place language assistance information in designated places w ithin the hospital (Joann, Cindy 10/12) Explore kp.org and regional waiting room videos as venues for providing members with culturally competent information e.g. rights to language services how to become active participants in their health, Ask Me 3 (Gayle, Cindy, Joann 10/12) Strat Map: Service 6

7 Standard 6 (mandate) Competency of Language Assistance Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). Created R:drive for Diversity Council shared documents (Joann 3/11) Interpretive and translation services are provided by approved vendors contracted by the Interpretive Services Program and/or National Procurement Office. Annual review of competency program of interpreter vendors for adequacy. Annual review of Language Assistance policy which addresses use of family / friends as interpreters. Develop program and curriculum to implement a bilingual staff training program with small test of change at Moanalua Medical Center to service 24/7 Emergency Department (Cindy, Joann 10/12) Review bilingual staff competency process & policy (Albert Mossman, Sarah, Joann 6/12) Develop process for annual review and regional communication of vendor competency documents (Joann, Cindy 6/12) Strat Map: Quality 7

8 Standard 7 (mandate) Translations and Signage Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. Created guideline & criteria for translation requests. Created Translation Request Form and Process and implemented use in 2011 (Jack, Cindy, Joann) Review and update for current information: o Translated member handouts such as Mother and Baby Care Hospital Discharge Instructions, Easing Your Pain, Patient Safety Brochure, and Important Message from Medicare. o Translated forms such as Blood Refusal / Consent Form, Informed Consent to Surgery, and Member Treatment Permit and Admission Agreement. o Translated materials located at online Clinical Library Translated Member Handouts. Continued review and management of content. Signage ordering process in Braille consistent with KP National sign standards. Annual data analysis of top five languages requested by patients per (1) appointments and (2) member count. Keep updated on National Facilities Services and National Diversity on their project with Hablamos Juntos on recommended universal symbols. National Internet Services Group collaboration to develop multilanguage patient instructions (Cindy 10/12) Develop Translation Policy (Joann, Gayle, Cindy 4/12) Explore National Facilities Services collaboration for universal and language specific signage, Contact: Michael C. Schroeder NFS Program Office (Joann, Cindy 10/12) Review and update Clinical Library translation links (Cindy, Teresa, Gayle 6/12) Strat Map: Service 8

9 Standard 8 (guideline) Organization Framework for Cultural Competence develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services. Developed 2011 Executive Summary on Cultural Needs and Preferences QI 4 element A for NCQA survey February 2012 and mock survey May 2011 (Joann 5/11)) Strengthened partnership between Diversity Council and Community Benefit formed August 2010 (Joy, Joann 10/11) Received 2011 R.J.Erickson Diversity Award a region-first in the Individual category (Joann 10/11) Annual review of Providing Language Assistance policy. Annual review of Diversity Council accomplishments and goals, and report up to National Diversity and senior leaders. Develop Diversity Strategy using National Diversity template on the refreshed diversity strategy (Diversity Council 2/12) Complete & submit annual CLAS report to National Diversity (Joann 3/12) Develop 2012 Executive Summary for NCQA Executive Summary on Cultural Needs and Preferences QI 4 element A (Joann 3/12) Strap Map: Service, Quality 9

10 Standard 9 (guideline) Organizational Self-Assessment conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomesbased evaluations. Integrated diversity standards throughout quality improvement standards (Susan, Joann 10/11) Developed 2010 Executive Summary on Cultural Needs and Preferences QI 4 element A for NCQA survey February 2012 (Joann 5/11) Achieved Medicare five STAR rating customer service call center on interpretive service & TTY utilization. (Joann, Customer Service Dept 10/11) Updated Cross Walk document which incorporates CLAS standards with NCQA, TJC, CMS, and Med-QUEST requirements. (Joann, 10/11) Diversity Council provides oversight to ensure diversity activities are in compliance with The Joint Commission, NCQA cultural needs assessment standards, and Med-QUEST cultural competency standards. EEO and diversity related performance is included on managers and supervisors performance evaluations. EEO plans and objectives are reviewed annually. Participate in National Diversity annual CLAS assessment (a written plan describing accomplishments and goals based on the CLAS Standards). New initiatives are based on the outcome of the evaluations. Effective 12/1/09, due to State s new reporting requirements, submit monthly Med- QUEST reports on interpretive service utilization for QUEST population. This report evaluates adequacy of interpretive services provided. Continual monitoring with telephone interpreter vendor, Language Line on quality of interpretive service (National Diversity & National Procurement, Joann 10/12) Participation in ADA Committee with EHS Erwin Soria. (Sarah, Cindy, Joann 10/12) Develop 2012 Executive Summary for NCQA Executive Summary on Cultural Needs and Preferences QI 4 element A (Joann 3/12) Strat Map: Quality 10

11 Standard 10 (guideline) Member Demographics Data Collection ensure that data on the individual patient s/consumer s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization s management information systems, and periodically updated. Implemented Meaningful Use Initiative Incentive Medicare payouts for threshold Demographics data collection, Race, Ethnicity, Language met 99% for clinics and hospital by year end (Joann, Jen Zimmerman 12/11) Diversity Council participation in National Diversity s inter-regional member demographic, race ethnicity and language preference data collection initiative. Collects in HealthConnect, automated medical record system, patient s interpreter need and spoken language data. Collects and enters data in HealthConnect using our Personal History Sheet (race, ethnicity, country of birth, gender) given to patients at first appointment visit, Admitting, and/or Emergency Department (started in 2006). Annual internal data analysis to determine top five spoken languages requested by our limited English proficient patients and non- English proficient patients (Cantonese, Korean, Vietnamese, Japanese, and Mandarin). Health Disparities Work (Rowena, Sharon Platt, Joann, Susan W 10/12) o Request for data from PO for Hawaii Region s Equitable Care Report (Demographics data for Hawaii Region breakdown of Asian Pacific Islander category, HEDIS Measures) o Review data and collaborate with diversity physician, primary care physician leadership to next steps to address health disparities (if any) Health Care Reform & HI Tech Act (Meaningful Use) continue to increase demographics data collection % for total membership population. Consider adding Written Language in the data collection efforts. (Joann, Jen 6/12) Strat Map: Quality, Finance 11

12 Standard 11 (guideline) Community Needs Assessment maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area. Unveiled State of Hawaii s first of its kind Community Health Needs Assessment (Joy, Community Benefit 6/11) Annual ethnicity demographic STAR survey conducted and analyzed. Comparison of ethnicity and demographic data among Hawaii U.S. Census 2010, Hawaii Health Survey 2005, CAHPS surveys (Commercial, Medicare, and Medicaid) 2008, and annual physician and non-physician workforce demographics. Cultural Needs Assessment done annually with NCQA efforts. Leverage our Community Health Needs Assessment in health disparities work (Joann, Joy 6/12) Strat Map: Service, Growth, Community Standard 12 (guideline) Community Partnerships CLAS Activities develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities. Unveiled State of Hawaii s first of its kind Community Health Needs Assessment (Joy, Community Benefit 6/11) Bilingual staff and physicians participated in marketing and community events (Jack, Joy, Joann 10/11) Ongoing partnership with local interpretive services vendor, Bilingual Access Line to improve language assistance services and with Hawaii Interpreting Services referral agency to improve sign language services. Implement process improvement with all vendors. Improve access and quality of service. Review diversity council representatives to reflect strategic focus and commitment to diversity. Explore Supplier Diversity s opportunities of minority owned businesses (Joy, Joann 10/12) Continued partnership with Grants Committee (Joy, Joann 10/12) Strat Map: Community 12

13 Standard 13 (guideline) Complaints & Grievance Resolution ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers. Strap Map: Service, Quality Strengthen partnership with contracted vendors who provide language services to identify, review, and resolve patient and staff concerns. (Joann 12/11) Reviewed Customer Feedback System data for 2010 to identify concerns or trends. Reported to Diversity council. (Joann 5/11) Health care reform translation requirements for Appeals process (John Nelson, Susan, Jack, Joann 12/11) Customer Feedback System (CFS) manages and monitors patient concerns. Annual review and summary of CFS for concerns relating to culturally competent care. The findings are also reported to NCQA QI 4 element A cultural needs and preferences. Partnership with contracted vendors who provide language services to identify, review, and resolve patient and staff concerns. Review survey data to evaluate concerns for demographic trends and customer satisfaction to protected classes. Strengthen partnership with contracted vendors who provide language services to identify, review, and resolve patient and staff concerns. Annual review of Customer Feedback System data for 2010 to identify concerns or trends. Report to Diversity council. Continued work on Health care reform translation requirements for Appeals process (John Nelson, Susan, Joann 1/12) 2011 CFS Summary Analysis (Joann 3/12) Standard 14 (recommendation) Information for Public Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information. Strat Map: Community Acted as community model and resource for Interpretive Services Program process with other healthcare organizations in the community. (Interpreter Services Program 12/11) No activity to report at this time. Develop public communication plan for Community Benefit activities (Joy 10/12) 13