Draft. Project to Develop Standards for Equity in Health Care for Migrants and other Vulnerable Groups

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1 HPH TF MFCCH Task Force on Migrant-Friendly and Culturally Competent Healthcare Draft Project to Develop Standards for Equity in Health Care for Migrants and other Vulnerable Groups Self Assessment Tool for Pilot Testing in Health Care Organisations 1

2 2

3 HPH TF MFCCH Task Force on Migrant-Friendly and Culturally Competent Healthcare Project to Develop Standards for Equity in Health Care for Migrants and other Vulnerable Groups Self Assessment Tool for Pilot testing in Health Care Organisations 3

4 This document has been developed by Antonio Chiarenza and the International Project Group on Standards for Equity in Health Care for Migrants and other Vulnerable Groups. It has been developed in accordance and in cooperation with the International HPH Secretariat. For further information contact: Dr Antonio Chiarenza (Coordinator) Task Force on Migrant-Friendly and Culturally Competent Health Care Regional HPH Network of Emilia-Romagna AUSL di Reggio Emilia Via Amendola, Reggio Emilia, Italy Phone: Fax: TF MFCCH Web site: HPH TF MFCCH Task Force on Migrant-Friendly and Culturally Competent Healthcare All rights reserved. The Task Force on Migrant-Friendly and Culturally Competent Health Care welcomes requests for permission to reproduce or translate its publications, in part or in full. 4

5 Contents page Presentation of the Task Force MFCCH Introduction The project aim The project group The project process Structure of the Standards References Standards for Equity in Health Care Framework of the standards Standard 1: Equity in Policy Standard 2: Equitable Access and Utilisation Standard 3: Equitable Quality of Care Standard 4: Community Involvement Standard 5: Promoting Equity Pilot Testing the Standards in Health Care Organisations The Pilot-Test Responsibilities The review form

6 6 Presentation of the Task Force MFCCH

7 Introduction The Task Force on Migrant Friendly and Culturally Competent Health Care is established within the international HPH network with a specific mandate for coordination assigned to the HPH regional network of Emilia-Romagna (Italy) by the General Assembly and the Governance Board of the international HPH network. The provider is the Health Authority of Reggio Emilia, which is the coordinating institution of the regional HPH network of Emilia Romagna. The Task Force was set up to continue the momentum created by the MFH project ( ) which involved 12 European countries engaged in the development of models of good practice for promoting health and health literacy of migrants and improving hospital services for these patient groups in selected pilot hospitals. The idea of creating a Task Force originated from the desire to continue working on these themes in a comparative international context after the conclusion of the MFH project, and to build on this experience in order: To facilitate the diffusion of policies and experiences and stimulate new partnerships for future initiatives; To foster cooperation and alliances between health care organisations and other networks; To support member organisations in becoming migrant-friendly and culturally competent health care organisations, as recommended in the Amsterdam Declaration (2004). 7

8 The approach of the TF was informed by some initial considerations regarding the dynamics of the migration phenomenon in Europe. The new situation created the condition for a more differentiated composition of migrants in terms of origin, legal status, motivations and levels of integration. The resulting growth in diversity requires health systems that take into account the differences in the needs, beliefs and practices concerning health and health delivery. Migrants and minority groups often suffer from poorer health compared to that of the average population. In addition to being more vulnerable due to low socio-economic position, unclear legal status and problematic migration experiences, specific analyses show that migrants may face inequity in health care services because of the existence of formal and informal barriers. Therefore, in order to reduce disparities in health care it is necessary to improve access and quality of health care services for migrants and other vulnerable groups. Here, the role of the Task Force is to support member organisations in this process of developing policies, systems and competences for the provision and delivery of equitable and accessible health care services for migrants and other vulnerable groups. 8

9 The project aim: to develop standards for equity in health care The decision to set up a project aiming at developing standards for equity was taken at the TF meeting held in Reggio Emilia on 15th October 2010 at the end of the scientific workshop Redefining the concept of cultural competence. Participants were: Arild Aambo and Ragnhild Spilker (Norway); Manuel Fernandez Gonzales (Sweden); Lai Fong Chiu (UK); James Robinson (Scotland); Gurwinder Gill (Canada); Ursula Karl-Trummer (Austria); Werner Schmidt (Germany); Antonio Chiarenza (Italy). The project represents the main activity of the work plan of the TF MFCCH and aims at developing specific standards to promote equity in healthcare. Equity is widely acknowledged as a core element of healthcare quality; yet, inequities in the provision of healthcare are severe and pervasive despite widespread documentation and numerous attempts to address them (See for example Solidarity in health: reducing health inequalities in EU, EU Commission 2009). This project aims at developing a comprehensive framework for measuring and monitoring the capacity of healthcare organizations to improve accessibility, utilization and quality of health care for migrants and ethnic minorities. Equity in healthcare implies equal entitlement for everyone, a fair distribution of services based on health care needs and the removal of barriers to access services and quality of care. 9

10 The project group The preliminary standards presented in this publication have been developed thanks to the active contribution of the following members: Antonio Chiarenza (Italy) Dagmar Domenig and Sandro Cattacin (Switzerland) Ragnhild Spilker and Bernadette Nirmal Kumar (Norway) James Robinson and James Glover (Scotland) Manuel Fernandez Gonzales (Sweden) Diane Nurse (Ireland) Lai Fong Chiu and Mark Johnson (United Kingdom) Morten Sodemann (Denmark) Manuel García-Ramírez (Spain) Gurwinder Gill, Elizabeth Abraham and Marie Serdynska (Canada) Ursula Karl-Trummer (Austria) 10

11 The project process Step 1: To develop the conceptual model in order to identify and organise standards and measurable elements based on a set of interrelated standards. Step 2: To identify the main standards for measuring and monitoring equity in healthcare. Step 3: To identify, for each main standard, a set of sub-standards and break these down into their principle components in order to allow for measurement so that they can be applied in the practical context. Step 4: To revise the proposed standards and review development of preliminary standards. Step 5: To present and discuss the preliminary standards at the International HPH Conference in Turku, Finland (1st-3rd June 2011) Step 6: To pilot test the preliminary standards in order to assess their clarity and ensure they meet the actual needs of people and services in health care organisations. Step 7: To collect and analyse the findings of the pilot test Step 8: To present the outcomes of the pilot test at the HPH International Conference (2012). Step 9: To produce the final standards and implement them in pilot organisations. 11

12 Structure of the standards Five standards have been developed addressing the following issues: Standard 1: Equity in Policy Standard 2: Equitable Access and Utilisation Standard 3: Equitable Quality of Care Standard 4: Community involvement Standard 5: Promoting Equity The standards for equity use the same format, terminology and development process adopted by the HPH standards: see the triple level structure of standards. 12

13 1 Equity Standard in policy The organisation promotes equity by providing fair opportunities in healthcare and contributes to reducing health differentials to the lowest possible level through the delivery of sustainable and cost effective policies. Standard definition Objective of the standard To define how the organisation should develop policies, governance and performance monitoring systems which promote equity Substandards The organisation has governance systems in place to ensure that decisions promote equity at all levels. The policy explicitly refers to activities to reduce inequities for patients, staff, and community. [Evidence: e.g.: strategy plans for patients, staff and community] Comments: Yes Partly No Substandard definition Measurable element Demostrable evidence Text box for comments, problems, goals, responsibilities, details on evidence and follow-up actions. 1. Level one is the level of the five main standards. The five standards address Equity in Policy; Equal Access and Utilisation, Equitable Quality of Care; Community Involvement and Promoting Equity. 2. Level two is the level of the substandards. Sub-standards operationalise the standard and break it down into its principle components. The number of substandards per standards varies from 4 to Level three are the measurable elements. Measurable elements are those requirements of the standard that will be reviewed and assessed to be not, partly or fully fulfilled. The measurable elements simply list what is required to be in full compliance with the standard. Listing the measurable elements is intended to provide greater clarity to the standards and help organizations educate staff about standards and prepare for the accreditation survey. 13

14 Reference Amsterdam Declaration (2004) ( Chiarenza, A. (2011), Developments in the concept of cultural competence, COST Action HOME Final Conference, Berlin ( CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization. EU Commission (2009), Solidarity in health: reducing health inequalities in EU, EU Commission, Bussels Marmot M. (2007). Achieving health equity: from root causes to fair outcomes. Lancet, 370: Whitehead, M. (2000). The concepts and principles of equity and health, Copenhagen, World Health Organisation WHO (2006) Implementing health promotion in hospitals: manual and self-assessment forms. Copenhagen, World Health Organisation Regional Office Europe WHO (2010) How health systems can address health inequities linked to migration and ethnicity. Copenhagen, World Health Organisation Regional Office Europe 14

15 15

16 16 Standards for Equity in Health Care

17 Framework of the standards This project aims at developing a comprehensive framework for measuring and monitoring the capacity of healthcare organisations to improve accessibility to appropriate and effective health services; health promotion and preventive care for migrants and other vulnerable groups. The aim is to develop and implement standards for equity in health care organisations that: Support the values of the international conventions on Human Rights, Social Justice, Professional Ethical Codes, etc. Acknowledge that there are inequities in health care and these inequities are unjust and must be redressed. These inequities are determined by power imbalances that exist in the dynamics between diverse populations and the health care system; Acknowledge and value multiple diversity typical of societies with a complex migration and colonial history and the existence of differences and commonalities in the local population. Aim at reducing inequality in the access to services and quality of care for all disadvantage groups. Support work to eradicate all forms of institutional discrimination based on ethnicity, gender, age, disabilities, religious beliefs and sexual orientation. 17

18 Acknowledge the right for individual self-determination and social justice. Acknowledge the uniqueness of all individuals and the respect of individual identity. Acknowledge that equity in health is one of the main factors of social, economic and political inclusion (WHO, 2010). Working definitions of equity: Equity in Health: is concerned with creating equal opportunities for health and with bringing health differentials down to the lowest possible. (M. Whitehead, 2000, p. 7) Equity in Health Care: is defined as equal access to available care for equal need; equal utilization for equal need; equal quality of care for all. (M. Whitehead, 2000, p. 8) 18

19 Standard 1Equity in policy The organisation promotes equity by providing fair opportunities in healthcare and contributes to reducing health differentials to the lowest possible level through the delivery of sustainable and cost effective policies. Objective of the standard To define how the organisation should develop policies, governance and performance monitoring systems which promote equity. 19

20 Substandards 1.1 The organisation has governance systems in place to ensure that decisions promote equity at all levels. 1.2 The organisation s research, monitoring and evaluation systems measure equity performance. 1.3 The organisation has a fully resourced plan in place which describes how it will develop capacity to promote equity, which is integrated with existing management instruments and is reviewed annually. 1.4 The organisation ensures that staff at all levels have relevant awareness and competence to address inequities in health care. 1.5 The organisation has a champion for equity at a senior/ executive level. 1.6 Equity is explicit in the annual performance objectives of all managers (including senior and executive managers). 20

21 Standard 2Equitable access utilisation and The organisation ensures for equal need, equitable access to available care and utilisation. Objective of the standard To encourage the health organisation to eliminate Legal barriers Multiple diversity barriers Linguistic barriers Information barriers Organisational barriers Financial barriers Resource barriers 21

22 Substandards 2.1 The organisation ensures the implementation of the right to health for all, in particular for disadvantaged groups. 2.2 The organisation has a good understanding of the characteristics of its population, including health inequalities. 2.3 The organisation ensures that physical accessibility to and distribution of health services are equitable and acceptable to all. 2.4 The organisation ensures that communication, health literacy and mistrust are not barriers to health services. 22

23 Standard 3Equitable quality of care The organisation provides high quality of care for all, acknowledging the unique characteristics of the individual and acting on these not only to improve individual health (through care, prevention and health promotion), but also social wellbeing. This means providing person centred care. Objective of the standard To assist the organisation in developing the following areas so that they respect the uniqueness of patients: patient assessment staff / patient interactions safe environment discharge and continuity of care 23

24 Substandards 3.1 The organisation ensures that procedures are in place to assess the needs of a multiple-diversity patient and population. 3.2 The organisation has systems in place to recognise individual patients experiences and living conditions, and is able to take account of the diverse concepts about health and illness in meeting their health care needs. 3.3 The organisation demonstrates that it is able to take into account the social context of the patient in order to improve the quality of care for the patient. 3.4 The organisation ensures that systems are in place to obtain feedback from all patients and that this information is used in service improvement. 3.5 The organisation is able to create an environment that is safe for the patient where there is no assault, challenge or denial of his/her identity. 3.6 The organisation is able to acknowledge and address the enactment of inequity, discrimination and racism. 24

25 Standard 4Community involvement The organisation provides for effective information and intervention through proactive and outreach group engagement of its community. Groups in the community are seen as active participants rather then passive recipients. Objective of the standard To support the organisation in the involvement of relevant communities in health service delivery and improvement. 25

26 Substandards 4.1 The organisation has effective channels of communication with its communities. 4.2 The organisation works in partnership with community based mediators/social workers, etc. to engage with communities in an inclusive way. 4.3 The organisation monitors the range of people who take part in participation activities. 4.4 The organisation has built evaluation into its participation processes. 26

27 Standard 5Promoting equity The organisation understands that it is part of a wider system and is able to promote the principles of equity across services. Objective of the standard To support the organisation in promoting equity externally in its wider environment through: Advocacy and lobbying Facilitating capacity building Disseminating research Developing education and promotional work 27

28 Substandards 5.1 The organisation is an active participant in policy networks/ think tanks/research initiatives which promote equitable approaches. 5.2 The organisation actively diffuses the results of research and practice, locally, regionally, nationally and internationally. 5.3 The organisation ensures that equity is reflected in all partnership agreements and relationships, suppliers, including contracted services and joint collaborations. 28

29 29

30 30 Pilot Testing the Standards in Health Care Organisations

31 Pilot-Test The scope of the pilot test is to assess the standards and not to assess the test-health care organisations. However, information about the actual compliance of the health care organisation to the standards will give important information about applicability and relevance of the standards themselves. The pilot test is furthermore expected to collect examples of demonstrable evidence (effective practices relating to the substandard) already in place in pilot institutions that can be used as measurable elements in the final lay out of the standards. Finally the pilot test aims to establish if the standards are accessible and understandable. The form below is to be used in the test. Provided the structure of the scheme remains unchanged, it may be returned in the national language. However, the national test coordinator must translate the comments and suggestions into English before returning the material to the HPH-Task Force MFCCH office (AUSL of Reggio Emilia). 31

32 Responsibilities HPH national networks are invited to be involved in the pilot testing of the preliminary standards. The HPH national coordinators in countries taking part in the pilot test are expected to: Identify and contract with 2 4 test hospitals/health service in the network. Organisations of different size and with an appropriate geographic distribution should be selected. Identify a responsible contact person who should take responsibility for the pilot test and report the results to the coordinator. Give appropriate instruction to the contact persons. Translate the test material into the national language. Take part in a workshop in Oslo (NAKMI) in March 2012 and among the contact persons in the test health care organisations identify 1 to be invited to the workshop. Compliance to the standards is reflected by the fulfilment of the substandard. 32

33 Example of the Review form Standard 1. EQUITY IN POLICY Description Objective The organisation promotes equity by providing fair opportunities in healthcare and contributes to reducing health differentials to the lowest possible level through the delivery of sustainable and cost effective policies. To define how the organisation should develop policies, governance and performance monitoring systems which promote equity. Substandard Content specification Substandard is relevant Substandard is applicable Test organization fulfils demands in this substandard Yes No Yes No Yes No Partially Comments and suggestions Demonstrable evidence in your organisation 1.1 The organisation has governance systems in place to ensure that decisions promote equity at all levels. 1.2 The organisation s research, monitoring and evaluation systems can measure equity performance 33

34 34 Notes

35 Notes 35

36 36 HPH TF MFCCH Task Force on Migrant-Friendly and Culturally Competent Healthcare

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