Quality Improvement Organizations (QIOs) and CLAS/Cultural Competency Ann Kenny, MPH, BSN, RN Project Director, SRA International, Inc. May 22, 2009

Quality Improvement Organizations (QIOs) and CLAS/Cultural Competency

Ann Kenny, MPH, BSN, RNProject Director, SRA International, Inc.

May 22, 2009

www.thinkculturalhealth.org2

Institute of Medicine 2002 Report – Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

Institute of Medicine 2002 Report – Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

Potential sources of disparities• Patients: minority patients are more likely to refuse

recommended services, delay seeking care, and not follow physician orders

• Health care system: places time constraints on physicians and restricts time to overcome language and cultural barriers

• Providers: more likely to rely on shortcuts due to time constraints

• Patients: minorities have more difficulty trusting their health care providers


Legislation, Accreditation, & RegulationLegislation, Accreditation, & Regulation

Dark Blue denotes legislation requiring (WA, CA, NJ, NM) or strongly recommending (MD) cultural competence training, which was signed into law.

Purple denotes legislation which has been referred to committee and is currently under consideration.

Royal Blue denotes legislation which died in committee or was vetoed.

NOTE: Cultural competency legislation is also being considered at the Federal level. Bill S.1576 has been referred to the Committee on Health, Education, Labor, and Pensions.

www.thinkculturalhealth.org


8th SOW: August 2005-20088th SOW: August 2005-2008

Task 1: Assisting Providers in Developing the Capacity for Achieving Excellence (TOTAL)• 1a: Nursing Home

• 1b: Home Health

• 1c1: Hospital

• 1c2: Critical Access Hospital/Rural PPS Hospital

• 1d1: Physician Practice IPG

• 1d2: Physician Practice/Underserved Populations

• 1d3: Physician Practice/Pharmacy: Part D Benefit


Task 1d2: Physician Practices/Underserved PopulationsTask 1d2: Physician Practices/Underserved Populations

QIO promotes adoption of CLAS Standards and completion of cultural competency requirements through OMH e-learning program.

QIO shall work with the IPG practice sites to assess adoption of the CLAS standards through a practice-site self assessment.

QIO shall provide assistance to the practice sites in meeting or exceeding at least one of the CLAS Standards 4-7.


Participants can: Watch streaming video case

studies or view transcripts Answer pre- and posttests

that provide immediate feedback and review missed questions

Receive instant online grading and CME/CEU certification at no cost

View other providers’ comments

Participate in self-assessment exercises

A Physician’s Practical Guide to Culturally Competent Care: The Cultural Competency Curriculum Modules (CCCMs)A Physician’s Practical Guide to Culturally Competent Care: The Cultural Competency Curriculum Modules (CCCMs)

Released in December 2004 Designed to equip providers with cultural and linguistic

competencies required to improve quality of care Accredited for physicians, physicians assistants, and nurse

practitioners


CCCM User StatisticsCCCM User Statistics

Over 32,000 registered users• 50% of registered users are MDs

• 56% of registered users are female

• 66% of users are White

• Nearly 1/3 of users are between the ages of 45-54

• Top specialties of participants are: family medicine, internal medicine, pediatrics, obstetrics/gynecology

130,000 credits awarded to participants• 59% of certificates awarded are CME certificates (physicians)

• 17% of certificates awarded are Statements of Participation (any participant for whom the course is not specifically accredited)

*As of 05.07.09


CCCM QIO User StatisticsCCCM QIO User Statistics

Aug 2005- July2006

Aug 2006- July2007

Aug 2007- July2008

02000400060008000

100001200014000

Cumulative Registrants: QIO vs. Non-QIO for 8th SOW

Cumulative QIO Registrants 1197 4246 5509

Cumulative Non-QIORegistrants

2087 6403 12256

Aug 2005 - July 2006 Aug 2006 - July 2007 Aug 2007 - July 2008


CCCM QIO User Statistics (cont’d.)CCCM QIO User Statistics (cont’d.)

Aug 2005- July2006

Aug 2006- July2007

Aug 2007- July2008

01000200030004000500060007000

Cumulative Credits Awarded: QIO vs. Non-QIO for 8th SOW

Cumulative Credits QIO 674 2547 3390

Cumulative Credits Non-QIO 795 2707 6136



CCCM QIO User Statistics (cont’d.)CCCM QIO User Statistics (cont’d.)

At Least One Theme Completed Rate Comparison:QIO vs. Non-QIO for 8th SOW

0%

10%

20%

30%

40%

50%

60%

70%

80%


QIO

Non-QIO


Two-Year Evaluation Report of the CCCMsTwo-Year Evaluation Report of the CCCMs

Evaluation Methodology Quantitative Qualitative

• Pre- and Posttest Scores

• Course Evaluation Questionnaire

• “Take a Moment” Questions

• Focus Groups

• Web-captured Comments

Conducted in December 2006, two years after launch Study Population:

• 2,213 participants total, 50.56% (n=1,119) affiliated with a QIO

• 42% Female, 58% Male

• 60% White non-Hispanic, 13% Asian, 11% Black, 8% Hispanic, 6% Other, 1% AI/AN, 1% NHOPI

Participant practice settings include:• Hospitals, Clinics, Private Practice, Community Health Centers

Common specialties:• Family Practice, Internal Medicine, Pediatrics


Evaluation ObjectivesEvaluation Objectives

Explore the extent to which completion of the curriculum results in physician self-reported improvements in:

1) Knowledge of culturally competent care models, principles, and theories

2) Attitudes toward diverse patient types

3) Utilization of interpreter services and translated materials

4) Practice habits

5) Educational/communication practices in direct physician-patient interactions


Objective 1: Increased knowledge of culturally competent care models, principles, and theories

Objective 1: Increased knowledge of culturally competent care models, principles, and theories

Physicians scored higher on posttests than on pretests • Score increases ranged from 1.01 (approx. 1 point) to

2.01 (approx. 2 points)

• Pretest scores ranged from 73% to 75%

• Posttest scores ranged from 83% to 94%


Objective 2: Change in attitudes toward diverse patient types Objective 2: Change in attitudes toward diverse patient types

73.8% of participants sympathized with American Indian patient featured in case study one• “I feel a lot of sympathy for Mrs. Williams. I believe Dr.

Brown means well, but he comes across as arrogant and uncaring.”

27.7% of participants directly expressed support for the patient in case study two and were concerned about the quality of care she received• “The office staff are providing very substandard care by

their underlying stereotyping.”


Objective 3: Change in use of interpreter services and translated materials Objective 3: Change in use of interpreter services and translated materials

Increased awareness regarding current interpreter practices• “One thing that impacted me was not using family

members as interpreters. A lot of times I’m forced to do that or it seems like the best method at the time, but now I can understand how certain issues may be sensitive to people, even if I don’t think they are sensitive issues.”

• “I really started to realize that having an interpreter is a good practice builder. It has been a boon to my practice.”

• “I learned a lot about dealing with interpreters. Recently, I had an interpreter who just took off talking to the patient because I did not tell him I wanted to be in charge of the conversation. Now I am a lot more in-tune and aware.”


Objective 4: Improved practice habits Objective 4: Improved practice habits

*Data from focus groups (N=53)

Level of Agreement


Objective 4: Improved practice habits for QIO participantsObjective 4: Improved practice habits for QIO participants

1

4

1 1

4

0

2

4

6

1 2 3 4 5 6 7 8 9 10

“Since completing the CCCMs, I believe I have actually changed my practice habits to reflect what I learned in the course.”

Level of Agreement


Objective 5: Enhanced educational/communication practices in direct physician-patient interactionsObjective 5: Enhanced educational/communication practices in direct physician-patient interactions

“I have applied at least one of the communication techniques that I saw in the vignettes in my daily practice.”

Level of Agreement

*Data from focus groups (N=53)

N


Objective 5: Enhanced educational/ communication practices in direct physician-patient interactions for QIO participants

Objective 5: Enhanced educational/ communication practices in direct physician-patient interactions for QIO participants

1 1

9

0

2

4

6

8

10

1 2 3 4 5 6 7 8 9 10

Level of Agreement

“I have applied at least one of the culturally competent communication techniques that I saw in the vignettes in my daily practice.”


QIO Survey Feedback QIO Survey Feedback

“The Facilitator’s Guide was extremely helpful. It is one of the most comprehensive, step-by-step guides for facilitating a curriculum that I’ve ever seen.”

“Participant interaction flows pretty naturally from the content, especially the video vignettes.”

“The video vignettes are great. Participants frequently cite them as the best part of the course, and they definitely promote the most discussion.”

“Participants enjoyed having a hard copy of the certificate to take with them.”


Summary of Findings Summary of Findings

Physicians enter CCCMs with a reasonable understanding of cultural competency, but show increased posttest scores and knowledge gain

Curriculum participation renders a positive impact on practice behavior• Increased sensitivity to cultural differences

• Took more time with patients

• Asked more patient-centered questions

Course resulted in improved perceptions of medical interpreters

Curriculum participation results in enhanced self-awareness of cultural competency concepts


For More Information, Contact: For More Information, Contact:

Ann Kenny, MPH, BSN, RN

Project Director

SRA International, Inc.

[email protected]

Documents

Quality Improvement Organizations (QIOs) and CLAS/Cultural Competency Ann Kenny, MPH, BSN, RN Project Director, SRA International, Inc. May 22, 2009