Cultural competency has been generally accepted as the term that describes, "the set of behaviors, attitudes and skills, policies and procedures that come together in a system, agency or individuals to enable mental health caregivers to work effectively and efficiently in cross/ multicultural situations". The promotion of cultural competency is rooted in the belief that understanding and respecting a person's cultural traits and values will be reflected in positive clinical and social outcomes. The need for these measures is highlighted by reports of the experiences of minority groups in mental health settings: high inpatient hospitalization rates disproportionate to those for the general population, misdiagnosis, language barriers, inappropriate planning, early terminations from treatment, and restrictions imposed by managed care.

While efforts to foster cultural competency standards in behavioral health care organizations have been underway for some time, earlier work has focused on identifying broad guidelines and standards of cultural competency and indicators that measure organizational and provider compliance to these principles. Researchers in this project, in conjunction with a multicultural steering committee and an expert panel comprised of planners, administrators, consumers, advocates and other stakeholders, and with input from provider and consumer focus groups, set out to:

i) develop a framework for a comprehensive selection of indicators,

ii) select a set of performance measures that could be applied to any multi-cultural group, 

iii) and identify potential data sources for these measures. 

RESEARCH ACTIVITIES AND RESULTS

More than 20 earlier reports on cultural competency developed by state/ federal agencies were reviewed and domains identified where it was felt that cultural competency standards would act to enhance the care delivery process. 

These domains include:

• Needs assessment: to provide a baseline of information profiling cultural groups within the communities served by a mental health organization.
• Information exchange: to provide ways for the mental health organization to receive and disseminate cultural information.
• Services: to assure that a process is in place for developing and monitoring equitable, quality services for all cultural groups
• Human resources: to look at activities to promote cultural competency among staff including training, recruitment, supervision, and grievance procedures
• Policies and Plans: to assess overall organizational policy
• Outcomes: desirable outcomes to be evidenced by clinical change, improved social functioning, recovery and self-empowerment that are consistent with the outcomes for the general population served.

The steering committee culled a list of more than 1300 statements from the reviewed papers that were either indicators, standards or guidelines. From these statements 117 indicators and 173 measures (quantifications of indicators) were identified and assigned to a domain factor within an organizational level, and data sources or instruments were suggested to collect the needed information. The validity of a selected indicator as a measure of the factor, its specificity in addressing a concern of cultural competency, the feasibility of collecting needed data and its expected reliability based on this data source were ranked. Some measures were eliminated, and some new measures added. The recommended list was then presented to focus groups who met at several sites across the nation, composed of 134 consumers, family members, advocates and providers, for discussion and review. A second expert panel meeting, augmented by consumers who had participated in the focus groups, reached consensus on a matrix of performance measures, one matrix for each organizational level, that yielded in total 52 factors, 163 indicators and 231 measures across the six domains and three organizational levels.

Several factors deemed critically important to the cultural competence of behavioral health care organizations were included: information about mental illness and the services provided needs to be disseminated in ways that respect the cultural values of consumers and families, the languages of program enrollees identified and met, and a social and physical environment responsive to different cultural backgrounds provided.

A final report that included a matrix of the cultural competency performance measures developed was submitted to SAMHSA.

INCLUSION OF GENDER AND MINORITY SUBJECTS:

Participants in focus groups:

SIGNIFICANCE OF FINDINGS/POLICY IMPLICATIONS

The need for cultural competency standards in behavioral health care programs has been increasingly recognized in order to provide for the sensitive and appropriate assessment and treatment of persons with mental illness from different cultural backgrounds. In managed behavioral healthcare organizations, whether under private or government auspices, this translates into improved fiscal efficiency by ensuring more timely engagement of persons in need of mental health care and reducing the reliance on costly emergency and inpatient services. Further, awareness and attention to cultural competence in program administration and service delivery is likely to increase consumer and family satisfaction and lead to improved clinical outcomes.

PLANS

A current project that extends this work is being conducted in conjunction with the Center for Mental Health Services Research, University of California at Berkeley. For the provider level of a care system, a subset of measures will be selected by expert multi-cultural panels based on criteria ranking of the importance and ease of implementation of the measures. For the selected list, questionnaires will be developed, where needed, benchmarks established based on activities conducted in best practice settings, and feasibility of implementation tested at other sites. Study sites for this project will be in both New York State and California.

PUBLICATIONS AND PRESENTATIONS

Publications:

Siegel C, Chambers E D, Haugland G, Bank R, Aponte C. (1998). A Framework for the Development of Performance Measures of Cultural Competency in Managed Care and Other Mental Health Organizations. Report Available from SAMHSA or  NYS Office of Mental Health or by contacting Gary Haugland, M.A. at the Center, tel: 914-398-6580.

Siegel C, Chambers E D, Haugland G, Bank R, Aponte C, McCombs H (2000). Performance measures of cultural competency in mental health organizations.  Administration and Policy in Mental Health 28(2): 91-106

Presentations:

Chambers, E.D. Moderator. The Future of Cultural Competency in Managed Behavioral Health Care; Aponte, C. Strategies for Developing and Implementing Cultural Competence; Haugland, G. Performance Measures of Cultural Competence; Blackshear, R. Consumer Input into Designing Performance Measures. Presented at the American Public Health Association 126th Annual Meeting, Washington, DC. Nov. 1998.

Siegel, C., Moderator. The Future of Cultural Competency in Managed Behavioral Health Care; Grantham, R. The Multicultural Advisory Committee in New York State; Blackshear, R. The Role of Consumers in the Advancement of Cultural Competency; Aponte, C. Development Strategies for Measuring and Implementing Cultural Competency; Haugland, G. A Conceptual Framework for Developing Performance Indicators of Cultural Competency. Presented at the NYS Office of Mental Health Research Conference, Albany NY, Dec. 1998.