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Cultural Competency - Joint Commission and CLAS Standards

The national CLAS standards are issued by the Office of Minority Health, Health and Human Services Department.  These standards are essential to providing culturally competent care to diverse patient populations and enhancing the patient-provider relationship. 

The Joint Commission also recognizes the importance of culturally competent care.  Since 2004, the Joint Commission (formerly known as JCAHO) has been studying how hospitals face and address challenges of providing health care to diverse populations, with the purpose to better understand what the current state of practice is and develop recommendations.

These standards drive the projects, services, and resources we engage in and provide.

JCAHO

Hospitals, Language and Culture Project

Resources and Standards

14 National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care

View examples of UMHS's compliance with CLAS. (internal users only)

Brochure

Audience:

The provision of CLAS is in the interest of and intended for use by:

These proposed standards are presented as guidelines for accreditation and credentialing agencies, to assess and compare providers who say they provide culturally competent services, and to assure quality for diverse populations.

This audience would include the Joint Commission on Accreditation of Healthcare Organizations, the National Committee on Quality Assurance, professional organizations such as the American Medical and Nurses associations, and quality review organizations such as Peer Review Organizations.

Organization:

These 14 standards are organized by themes:

These 14 standards are also organized by varying stringency levels:

The standards are intended to be inclusive of all cultures and not limited to any particular population group or sets of groups; however, they are especially designed to address the needs of racial, ethnic, and linguistic population groups that experience unequal access to health services.

To learn more about CLAS:

CLAS in Healthcare - 14 National Standards

Culturally Competent Care

  1. Health care organizations should ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.
  2. Health care organizations should 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.
  3. Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

Language Access Services

  1. 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.
  2. 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.
  3. 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).
  4. 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.

Organizational Supports for Cultural Competence

  1. Health care organizations should 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.
  2. Health care organizations should 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 outcomes-based evaluations.
  3. Health care organizations should 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.
  4. Health care organizations should 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.
  5. Health care organizations should 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.
  6. Health care organizations should 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.
  7. 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.

Source:
Assuring cultural competence in health care: Recommendations for national standards and an outcomes-focused research agenda. (2001, March).