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The following self-assessment tool was developed by Mike Carter, regional manager at the Office of Civil Rights (OCR) in New York City, and a variety of health care professionals and organizations in the state. It is not a policy guide or enforcement document from the OCR.
He views it as "a road map that your agency or facility can use to determine how accessible you are to racial and ethnic minority patients." Not every question may apply to your particular case, and the ultimate goal should be for an institution to be able to determine why certain patient populations do not access a particular facility or service and how this situation can be remedied.
The tool is a work in progress. If you have suggestions for input or update, contact Carter at email@example.com.
Carter says the first step in doing the assessment is to appoint a coordinator and establish a self-assessment committee with a cross-section of staff representing the protected classes. The coordinator or committee chair should be an individual with sufficient authority within the organization to take the needed actions.
The committee should include persons who have responsibilities in admissions and intake, provision of services, personnel administration, and physical plant management, as well as specialists who work with disabled persons. The committee should ask the following questions:
1. What is the actual geographic service area for your facility? Has your facility recently reviewed patient demographics? Do you know the current racial, gender, age, and geographic distribution of your patient population? Review patient discharge data that your facility gathers. This can help you determine exactly who you serve.
2. Do you have a breakdown of your facility’s service area by race and/or national origin and age? You can check U.S. Census Bureau data, state and local population data, and statistical models to find this information.
3. Do you operate any satellite facilities? If so, where are these facilities located? What type of services do these facilities offer? What is the racial and/or ethnic breakdown of the patient population that uses these facilities. (Use most recent data available.)
4. Identify your patients/clients by race, ethnicity, age, disability, and primary source of payment.
5. List your facility’s major referral sources. Do you have referral sources in minority communities? Consult minority community representatives to assure that these referral sources are adequate.
6. Does your facility’s service area include one or more national origin minority groups (i.e., Hispanic, Chinese, Russian, Polish, Italian, etc.) with at least 100 persons of limited English proficiency (LEP)?
7. What are the most sophisticated medical services that your facility is known for? What is the racial and/or ethnic breakdown of the patients who have received these services during the last calendar year?
8. Does your facility offer emergency room services? If so, what is the racial and/or ethnic breakdown of the patient population treated in your emergency room during the last calendar year? How many of the patients seen in your emergency room were admitted to your facility? What is the racial and/or ethnic breakdown of this patient group?
9. Does your facility have a nondiscrimination policy? If so, how do you train your staff in this policy? How is the policy updated? How are staff informed of updates? Is the policy reviewed regularly? Are your nondiscrimination policies posted in public areas? Are they printed in facility publications? Are those publications available in languages other than English? If so, what other languages? Do those languages correspond to the languages spoken in your facility’s service area?
10. Have you notified participants, applicants, and employees that you do not discriminate on the basis of race, color, national origin, age, or disability?
11. Do your written materials include a notice of nondiscrimination on the basis of race, color, national origin, age, or disability?
12. Have you designated someone to coordinate your efforts to comply with Title VI of the Civil Rights Act of 1964? If so, what authority does that person have to correct situations that may violate Title VI? Does that person have the necessary resources to perform the job?
13. What type of marketing of your facility is conducted by TV, radio, print, billboards, mailings, ethnic media, and community media? Where is it conducted? Which services (e.g. cardiac care, diabetes care) are marketed? Is any marketing aimed at non-English-speaking populations? If so, which populations and in what language?
14. Does your facility conduct any type of community outreach? If so, what type? To which communities?
15. Identify the total number of patient contact staff by race, ethnicity, and position held? (e.g. RNs, LPNs, admission staff, etc.)
16. Identify the total number of physicians with staff privileges by specialty, race, ethnicity, and type of position held. If different from staff privileges, specify the total number of physicians with admitting privileges by specialty, race, ethnicity, and location of office. Do any of these physicians serve predominantly minority communities? What efforts does your facility have in place to recruit minority physicians, nurses, and other medical professionals? If your facility does actively seek minority health professionals, where and how are these individuals sought?
17. What is the racial and/or ethnic and gender composition of your board of directors? What role does your board play in community outreach decisions? Admitting and staffing privileges? Marketing decisions?
18. Does your facility have any particular affiliation with medical schools, nursing schools, etc.? If so, which schools?
19. Does your facility have any relationship with community-based organizations? If so, which organizations? What is the nature of the relationship?
20. Is there any type of racial and/or ethnic sensitivity training (e.g. cultural medical competence) for your staff or a particular element of your staff? If so, what type of training? How extensive is it? What percentage of your staff availed themselves of this training? Is the training conducted by a contractor or by in-house staff? If by a contractor, who is the contractor? If this training program exists, has it been evaluated? If so, by whom?
21. In some racial and ethnic minority communities, there is an historical and/or cultural mistrust of the medical profession (especially within the African-American community in light of such things as the Tuskegee Study and segregated hospitals that are still remembered by older patients). This can cause patients to avoid medical checkups and even avoid medical help when ill. What does your facility do to try to overcome this problem? Is it successful? If not, what are you doing to address the situation?
22. What are the procedures in place for assisting LEP patients or clients? Are LEP patients forced to wait an unreasonable amount of time for interpreter services? Do your frontline staff know what to do when LEP patients present themselves? How do they know what to do? Who maintains staff training standards on this issue? Is staff conduct in this context monitored? By whom?
23. Can you identify staff who are fluent in languages other than English? What role do these staff members play in providing interpreter services to LEP patients? Who monitors the quality of the interpretation? What standards are used to evaluate the interpretation?
24. Does your institution contract out for interpreter services? If so, with whom? What are the qualifications of those contractors? Are they trained or certified in medical interpreting? Who evaluates the work performed by the contractors?
25. Determine what signs, postings, and other printed materials are translated into languages spoken by LEP patients and clients who use your institution. Has everything that must be translated to allow for equal access been translated? Who provides the translation service? How do you determine if the translations are accurate?
Source: U.S. Department of Health and Human Services, Office of Civil Rights, Region II, New York City.