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Human Resources

Human Resources

CLAS standards

Type one

Mandates required by current federal laws for all recipients of federal funds...these standards are the most critical level of stringency and are "mandated". This does not mean they are the highest standards or best practices. Type One standards relate to Title VI of the Civil Rights Act of 1964 Policy Guidance on the Prohibition Against National Origin Discrimination as It Affects Person with Limited English Proficiency (LEP).

Title VI's "promise" is equal access to federally assisted programs and activities. This includes all entities and public or private individuals whose program or activities receive federal financial assistance from Health and Human Services, either directly or indirectly, through a grant, contract or subcontract. This includes all health care organizations and out patient services. As an institution that receives federal funds, UC Davis Health System is required to implement these "mandated" standards.

Type two

Guidelines recommended for adoption as mandates by federal, state and accrediting agencies...these standards are the "guidelines" currently recommended for adoption as mandates by federal, state and accreditation bodies.

Type three

Suggestion(s) recommended for voluntary adoption by health care organizations...these standards are "suggestions" recommended for voluntary adoption by health care organizations.

CLAS standards 1 - 14

Standard 1:

Health care organizations should ensure that patient/consumers receive from all staff members effective, understandable and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

Standard 2:

Health care organizations should implement strategies to recruit, retain and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.

Standard 3:

Health care organization should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

Standard 4:

Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with Limited English Proficiency (LEP) at all points of contact, in a timely manner during all hours of operations.

Standard 5:

Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

Standard 6:

Health care organizations must assure the competence of language assistance provided to LEP patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).

Standard 7:

Health care organizations must make available easily understood patient related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the services.

Standard 8:

Health care organizations should develop, implement and promote a written strategic plan that outlines clear goals, policies, operational plans and management accountability and oversight mechanisms to provide culturally and linguistically appropriate standards.

Standard 9:

Health care organizations should conduct initial and ongoing organizational self assessment of CLAS related activities and are encouraged to integrate cultural and linguistic competence related measures into their internal audits, performance improvement programs, patient satisfaction assessments and outcomes based evaluations.

Standard 10:

Health care organizations should ensure that data on the individual patients'/consumers' race, ethnicity and spoken and written languages are collected in health records, integrated into the organization's management information systems and periodically updated.

Standard 11:

Health care organizations should maintain a current demographic, cultural and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

Standard 12:

Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS related standards.

Standard 13:

Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing and resolving cross cultural conflicts or complaints by patients/consumers.

Standard 14:

Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS Standards and to provide public notice in their communications about the availability of this information.