Growing a Culturally Competent Workforce

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Growing a Culturally Competent Workforce

• Peter Jansen
• MB ChB, FRNZCGP, Grad Cert Cln Tch
• Director of Research, Mauri Ora Associates
• November, 2006

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Growing a Culturally Competent Workforce

• Peter Jansen
• Ngati Raukawa
• November, 2006

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Outline

• Drivers of cultural competency in New Zealand
• Research base
• Cultural competence training
• Who, what, when, and how to teach
• Who will teach?
• Assessments of competence
• Assessing the assessors
• Examples of resources, learning programmes

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Why do this? (1)The State of Maori Health

• Maori have the greatest levels of health
  inequality in New Zealand, with measures of
  mortality and morbidity showing significant gaps
  compared to non-Maori even after controlling for
  deprivation
• Disparities in access to care and outcome have
  been found in preventive services, primary care
  services, mental health, hospital services,
  injury services, home help, income support,
  complaints and compensation for medical error,
  etc etc

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Injury to Maori

• Overall ethnicity data collection by ACC is very
  good (95 of new claims)
• Maori claimants are younger cf non-Maori
• Maori have lower claim rates and lower fatality
  rates than non-Maori,
• This is especially so for non-earner claims
• Is this due to
• Not claiming? Lesser access?
• Fewer accidents?
• Not giving ethnicity or stating ethnicity
  differently than at census?

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Lower Access for Maori
First treatment provider claims per 1000 pop,
2002/03

• Maori account for 11 of medical fees claims and
  claims cost less
• Average medical fees claims, 2002/03
• Maori Average per claim 114.14
• Non-Maori Average per claim 132.90

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Maori Access to primary care

• Crengle S, Lay-Yee R, Davis P, Pearson J. 2005
• A Comparison of Maori and Non-Maori Patient
  Visits to Doctors The National Primary Medical
  Care Survey (NatMedCa) 2001/02. Report 6
• Available from www.moh.govt.nz

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NatMedCa Report 6

• Doctors reported a lower level of rapport with
  Maori than non-Maori, and
• Maori had lesser mean length of consultations
  (13.7 minutes vs 15.1 for non-Maori)
• Maori had fewer tests ordered but slightly more
  prescriptions written

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What GPs say about Maori

• In terms of compliance Pakeha GPs say that Maori
• Present late, do not follow prescribed regimens
  of treatment, do not attend regularly or
  sufficiently frequently, and dont attend follow
  up
• Do not take their medication, do not arrange for
  repeat courses of medication
• Do not know their personal medical history, dont
  know what medications they have taken nor why
  they are taking medications
• Have different attitudes and expectations about
  health, based in a present-focused, laissez faire
  world-view
• Do not embrace preventive medicine and they
  expect a quick-fix solution in a crisis
• Authors conclude that these repertoires either
  blame Maori for their plight or justify existing
  service provision
• NZMJ 13 December 2002, Vol 115 No 1167
• URL http//www.nzma.org.nz/journal/115-1167/272/

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Why do this? (2)Contractrual
Public funders may require organisations to
demonstrate cultural competence, eg

• Primary Health Organisations (PHOs) funding
  related to disadvantage incl ethnicity
• PHOs must develop Maori Health Action plans to
  address inequalities
• Accident Compensation Corporation (ACC) has
  included Hauora competency standards into service
  contracts
• ACC has resources to support Hauora competencies,
  eg booklets, summaries, seminars, DVD

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Why do this? (3)The Law

• Health Practitioners Competency Assurance (HPCA)
  Act 2004
• covers all registered health professionals
• Section 118 requires registration bodies to
• develop ethical standards, standards of cultural
  competence and standards of clinical competence
• ensure that practitioners meet those standards
• Registration bodies must assess performance and
  re-certify health professionals

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Registration Bodies

• Some have started to develop cultural competence
  standards, eg
• Medical Council
• Medical Laboratory Scientists Board
• Nursing Council of New Zealand
• Physiotherapists Council ,
• Dental, Podiatry, Occupational Therapy boards
  etc

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Medical Branches

• Some Branch Advisory Bodies (BABs) have developed
  / adapted standards, eg
• Australasian Faculty of Public Health Medicine
• Royal New Zealand College of General
  Practitioners

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Effective CC Teaching

• Review by AHRQ, 2004
• Strong evidence that CC training improves
  knowledge,
• Good evidence that CC training improves attitudes
  and skills of healthcare providers,
• Some studies suggest that CC training improves
  patient satisfaction, and
• Limited evidence that adherence to care is
  improved.
• United States Agency of Health Research and
  Quality Evidence Report/Technology Assessment No
  90 Strategies for Improving Minority Healthcare
  Quality, January 2004

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Does it work in practice

• Targeted programmes can improve minority
  healthcare, eg tracking and reminder systems for
  cancer screening, smoking cessation
• Especially when linked to training to improve
  knowledge, skills and attitudes
• But not general programmes
• United States Agency of Health Research and
  Quality Evidence Report/Technology Assessment No
  90 Strategies for Improving Minority Healthcare
  Quality, January 2004

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Competence to performance

• NZ registration bodies are developing standards
  the knowledge, skills, attitudes and judgements
  required for safe practice
• But this must be followed by checking performance
  against competency standards
• HPCA Act requires that HPs be shown to practice
  safely

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Performance Measures

• Overarching goal of equity (equality of outcome)
• Health status and determinants of health
• Access to service (by ethnicity, gender, etc)
• Effectiveness of service
• Clinical effectiveness (medical audit)
• Communications (service user / co-worker
  evaluations, video reviews simulated patients
  etc)
• Complaints (peer / service user ratings)
• Ultimately, independently verifiable audits of
  processes and outcomes

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Who to teach?

• Undergraduates
• Overseas trained doctors and doctors returning to
  the workforce
• General and vocational registrants
• KSA need updating, reinforcing, extending
• Cultural competence is a lifelong commitment,
  just like clinical competence

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Who will teach?

• Who will teach?
• Who will assess?
• What are they assessing?
• Who will assess the assessors?

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Assessing the assessors

• Use of knowledgeable people including doctors
  from Maori or other cultures to develop curricula
  
• Oversight by cultural experts
• Training for assessors and supervisors (note NZ
  intern supervisors)
• Recertification of training programmes for
  assessors

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Examples

• RNZCGP framework and guidelines for culturally
  competent general practice in New Zealand
• MCNZ Statement on culturally competent care when
  dealing with Maori patients, and a booklet

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Medical Council of NZ

• Complementary statements Cultural Competence
• and
• Best practices when providing care to Maori
  patients and their whanau
• Resource booklet on Best Health Outcomes for
  Maori Practice Implications

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MCNZ Statement on Cultural Competence

• Background
• Definition
• Responsibilities
• Standards
• Attitudes, knowledge and skills required
• References, links and expiry date

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MCNZ Statement on Best practices when providing
care to Maori

• Purpose and Introduction
• Health and other disparities
• The impact of disparities on Maori
• Issues from existing MCNZ publications
• The MCNZ definition of cultural competence
• Key issues for Maori
• Principles of culturally competent care for Maori
• Maori cultural competence standards
• References, links and expiry date

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Booklet

• In-depth information on how to anticipate and
  accommodate culturally-based issues that may
  arise when dealing with Maori patients and their
  families
• Extends the statements, eg
• Case studies
• Glossary of Maori terms
• References, links and expiry date

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Specific Topics

• Maori pronunciation
• Family/whanau support
• Initial contacts and protocols
• Examining patients
• Physical contact
• Body language
• Sharing information and consent
• Traditional medicine

• Karakia and use of cultural experts
• Special issues
• Surgery
• Anaesthesia
• Mental Health
• Pain
• Hospitals
• Mate Maori
• Death and dying
• Autopsies

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Cultural Competence - Key points

• Knowledge of cultures, including own
• NZ context Maori issues and the Treaty of
  Waitangi
• Commitment to lifelong learning about cultures
  and cross-cultural communication
• Incorporate into educational pathways and
  continuing education
• Guidance for providers, training for assessors
• Expert oversight
• Evidence-based development of resources
• Move to independent, verifiable measures of
  performance

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peter_at_mauriora.co.nz Mauri Ora
Associates Auckland and Hamilton www.mauriora.co.n
z Ph. 09 3764964