Standard 10: Organizational Assessments – Texas System of Care Toolkit

Back to: Ensuring Cultural and Linguistic Competence

Standard 10 of the National CLAS Standards states that organizations should conduct ongoing assessments of their CLAS-related activities and integrate CLAS-related measures into ongoing quality improvement activities. Organizational assessments can be a great starting point for evaluating the current level of integration of CLAS Standards, which is an indicator of effective cultural and linguistic practices. These assessments can consist of a mix of different methods (interviews, focus groups, surveys, etc.) and will give the most useful results when they include not only responses from leadership and staff, but also from board members, funders, clients served, volunteers, and anyone else who may have some level of knowledge about the agency’s services and impact on the larger community. If participation is limited to only employees of the organization, the results will show a bias and may reveal only minimal areas for improvement.

HHS’s Blueprint for advancing and Sustaining CLAS Policy and Practice provides a table titled, “A Process for Collecting Data” (on page 115), also shown below.

When?	Ask for data early — ideally, during admission or registration
Who?	Properly trained admissions or reception staff could collect data
What will you tell individuals?	Before obtaining information, develop a script to communicate that: This information is important. It will be used to improve care and services and to prevent discrimination. This information will be kept confidential. In addition, address any concerns up front and clearly.
How?	Individual self-report — select their own race, ethnicity, language, etc.
What information will you collect? (Individual Data)	Race Ethnicity Nationality Nativity Ability to speak English Language(s) other than English spoken Preferred spoken/written languages or other mode of communication Age Gender Sexual orientation Gender identity Income Education Informed of right to interpreter services Request for, and/or use of, interpreter services Treatment history Medical history Outcome data (service type, utilization, length of stay) Client satisfaction See also aforementioned HHS Data Collection Standards
What information will you collect? (Staff Data)	Race Ethnicity Nationality Nativity Primary/preferred language Gender Records of cultural and linguistic competency training participation and evaluations
Tools to collect and store data	Use standard collection instruments. Store data in a standard electronic format

In addition, it is important to make sure that all populations served by the agency are proportionately represented in survey responses. For example, if clients of one program are invited to participate because getting responses is logistically easier than in other programs, the client responses cannot be considered reflective of client responses from agency services as a whole. Special attention and effort (in other words, equity in effort) need to be paid to make sure that all groups of people are represented in the responses. This also includes making sure that the racial/ethnic, socio-economic status, transportation status, language abilities, etc. are considered and properly represented in final assessment responses.

In addition to organizational assessments dedicated to assessing cultural and linguistic competence, implementing an equity lens into already existing assessments allows opportunity for ongoing input. It’s beneficial to review all client surveys that are required by the agency, funders, etc. and see if the existing surveys address CLAS standards in some manner. If they do, and the agency is not tracking these responses before sending away results, the agency can begin to track and monitor responses to those particular items. If existing surveys do not address CLAS in some way, then the workers in charge of collecting survey responses could also be asked to take note of a couple additional questions specifically created to measure whether the client’s experience with the agency has met their specific cultural and linguistic needs.

One tool that could help get started with this process is the CLC Assessment Tool: Based on the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS Standards) from the TA Network. In addition, some organizations have created their own assessment tool, including the Indiana Prevention Resource Center’s CLAS Standards Checklist/Assessment Tool. Finally, there are companies that can conduct a CLAS Standards Organizational assessment for a fee, including Stratis Health and CM ELearning.

For additional assessments, see lists compiled by Virginia’s Department of Health and Georgetown University’s National Center for Cultural Competence.