Refuah Community Health Collaborative

Refuah Community Health Collaborative

Promoting Cultural and Linguistic Competency

Self- Assessment Questionnaire for

Administrators and Personnel Providing Primary/Behavioral Health Care Services

The intent of this self-assessment questionnaire is to help us evaluate our efforts to provide services to our patients in a manner that accommodates their diverse cultural and linguistic needs. It should be viewed as an indication of areas in which the organization and staff can, over time, enhance attitudes, practices, policies, and structures concerning service delivery to a diverse population. Your responses are strictly confidential and will not be used to reflect negatively on you or anyone in the organization. Your participation is greatly appreciated as it will help us to identify opportunities for improvement.

Date of Self- Assessment:

Participant Information
1. / Years of Service at this Organization:
□ < 1 year □ 1-3 years □ 4-6 years □ 7-10 years □ > 10 years
2. / Area/Job Category: □ Reception/Call Center □ Clinical □ Administration
3. / What languages do you speak and/or read well? (Check all that apply)
Others (please specify)
□ Creole □ English □ Hebrew □ Hindi □Italian □ Korean / □
□ Mandarin (or other Chinese) □ Polish □ Portuguese □ Russian / □
□ Spanish □ Tagalog □ Urdu □ Yiddish / □
Patient/Client Information
4. / What languages do your patients use as their primary languages? (Check all that apply)
Others (please specify)
□ Creole □ English □ Hebrew □ Hindi □ Italian □ Korean / □
□ Mandarin (or other Chinese) □ Polish □ Portuguese □ Russian / □
□ Spanish □ Tagalog □ Urdu □ Yiddish / □
5. / Does your organization serve any individuals who self-identify as any of the following? (Check all that apply)
□ Latino/Hispanic / □ Hasidic/Orthodox Jewish / □ Physically Disabled / □ Intellectually or Mentally Challenged
□ African-American / □ East Asian / □ Hearing Impaired / □ Impoverished
□ Haitian / □ Lesbian, gay, bisexual, transgender, queer and/or questioning, intersex (LGBTQI) / □ Vision Impaired / □ Undocumented/ refugees
□ South Asian / □ Other (specify) / □ Other (specify)
Section One: Clinical Services
For each statement, check “Yes” or “No.” If you don’t know or the statement is not applicable to your position, check the corresponding box
1. / Our organization demonstratesits accessibility and willingness to meet the needs of our patient population by offering evenings and weekend hours. / □ Yes / □ No / □ Don’t Know
2. / Our organization demonstrates its accessibility and willingness to help meet the needs of our patient population by facilitating transportation services. / □ Yes / □ No / □ Don’t Know
3. / Our organization posts notification of the right to an interpreter in several languages at various points of contact by various means (print or multimedia). / □ Yes / □ No / □ Don’t Know
4. / Our organization has signs in the languages of the population groups we serve. / □ Yes / □ No / □ Don’t Know
5. / Our organization has sufficient trained interpreters (both in-house and online) easily available for various languages, including sign language. / □ Yes / □ No / □ Don’t Know
6. / Our organization trains interested staff as medical interpreters by using training programs and online resources and creates incentives and recognition for participating. / □ Yes / □ No / □ Don’t Know
7. / Our organization has developed a list of various community resources we can use for referrals to better serve our patients of various cultural groups. / □ Yes / □ No / □ Don’t Know
8. / Our organization displays pictures, artwork and other decor that reflects the cultures and ethnic backgrounds of patients we serve. / □ Yes / □ No / □ Don’t Know
9. / Any printed information disseminated by our organization takes into account the average literacy levels of individuals and families receiving services. / □ Yes / □ No / □ Don’t Know
10. / Our organization ensures that magazines, brochures, and other printed materials in reception areas are of interest to and reflects the different cultures served and screensfor negative cultural, ethnic or racial stereotypes of individuals and families served. / □ Yes / □ No / □ Don’t Know
Section Two: Training and Staff Development
For each statement, check “Yes” or “No.” If you don’t know or the statement is not applicable to your position, check the corresponding box
1. / During my orientation, I participated in a program on cultural diversity that enhanced my knowledge of the ethnic and/or cultural groups served by my organization. / □ Yes / □ No / □ Don’t Know
2. / Since my hire date, I have had further training about the various social, cultural, and/or ethnic issues that affect the health of the patients we serve. / □ Yes / □ No / □ Don’t Know
3. / As part of an in-service or other training, I have had the opportunity to evaluate my own cultural and ethnic beliefs and potential biases and prejudices that may influence my behavior at work. / □ Yes / □ No / □ Don’t Know
4. / In the past, I have attended training about how to better serve my patients who are culturally and ethnically different from me. / □ Yes / □ No / □ Don’t Know
5. / Our organization requires diversity awareness and cultural competence training at all levels of the organization (i.e., staff, management, providers, etc.). / □ Yes / □ No / □ Don’t Know
6. / In the past year, our organization sponsored at least one activity that has helped improve communication and teamwork between employees of different cultural, language, and ethnic groups. / □ Yes / □ No / □ Don’t Know
7. / Representatives of the diverse cultures are actively sought to participate in the planning and presentation of training activities. / □ Yes / □ No / □ Don’t Know
8. / In most circumstances, I am able to communicate with people who are different from me without fear or anxiety. / □ Yes / □ No / □ Don’t Know
9. / I am flexible, adaptive, and will initiate changes, which will better serve patients and families from diverse cultures. / □ Yes / □ No / □ Don’t Know
10. / I intervene, in an appropriate manner, when I observe other staff members engaging in behaviors that appear culturally insensitive or reflect prejudice. / □ Yes / □ No / □ Don’t Know
Section Three: Administration
For each statement, check “Yes” or “No.” If you don’t know or the statement is not applicable to your position, check the corresponding box
1. / Our organization’s mission statement, policies and programs include an explicit commitment to cultural and linguistic competence. / □ Yes / □ No / □ Don’t Know
2. / Our organization consults regularly with culturally diverse communities to identify cultural diversity issues in the service areas. / □ Yes / □ No / □ Don’t Know
3. / Our organization’s recruitment, hiring, retention and promotion practices achieves a diverse and culturally competent staff, including senior leadership, reflective of our patient population. / □ Yes / □ No / □ Don’t Know
4. / Our organization has a formal grievance/complaint process that is accessible to all patient population. This may include concerns or complaints regarding unfair treatment due to their race, ethnicity, or the language they speak. / □ Yes / □ No / □ Don’t Know
5. / Our organization consistently collects race, ethnicity, and preferred language for all of our patients in health records. (If you collect 2 out of 3 enter Yes). / □ Yes / □ No / □ Don’t Know
6. / Our organization has a person/position with responsibility for implementing and monitoring cultural competence activities (e.g., Health Literacy Officer or Health Literacy Task Force or added responsibility to a high level position). / □ Yes / □ No / □ Don’t Know
7. / Our organization conducts consumer surveys that are designed to be understandable and easy to complete to assess satisfaction/dissatisfaction of the services provided. / □ Yes / □ No / □ Don’t Know
8. / Resources are in place to support initial and ongoing training for personnel to develop cultural competence. / □ Yes / □ No / □ Don’t Know
9. / Our organization regularly provides information to the public through print materials and activities highlighting our efforts to provide culturally responsive care to all patients. / □ Yes / □ No / □ Don’t Know
10. / Fiscal resources are available to support translation and interpretation services including funds for training in-housestaff who may be interested to participate. / □ Yes / □ No / □ Don’t Know

Thank you for taking the time to fill out this self- assessment. Your answers will be combined with all the other staff members who complete the questionnaire. If you feel that you could use additional training in a particular area, have additional comments, orpleasedescribe in the space below.