The elements in the Healthy Diversity Assessment Tool

HERE WE ASK QUESTIONS LIKE:

• What are the contextual circumstances and the context of the practice?
• What category and area of healthcare practice are we dealing with?

WHAT DOES THE CONTEXT INCLUDE IN THE ASSESSMENT TOOL?

In the assessment tool, the healthcare context would include both the category and the area of the healthcare practice:

CONTEXTUAL CIRCUMSTANCES:

• The good practice concerns procedures for healthcare treatment, for instance emergency, medical treatment etc.
• The good practice concerns procedures for healthcare training, for instance vocational education, internships, organizational training etc.
• The good practice concerns procedures for special needs, for instance interpretation, religious/cultural facilities, environmental facilities etc.

CATEGORIES:

• Organisational efforts to practice diversity management in healthcare services, for instance in management procedures for a hospital ward
• Training and development of intercultural skills and competences to meet diverse user group and diverse needs in healthcare services
• Many good practices may include both a diversity management and an intercultural competence perspective.

AREAS IN THE HEALTHCARE PRIMARY SECTOR:

• Local healthcare centres, outpatient treatment services, nursing homes and other institutions as part of local/municipal healthcare services
• GP´s and specialized doctors
• NGO´s and private healthcare efforts etc.

AREAS IN THE HEALTHCARE SECONDARY SECTOR:

• Hospitals, including medical wards, surgical wards, emergency wards, psychiatric wards
• Hospices etc.

HERE WE ASK QUESTIONS LIKE:

• What are the actors and relations involved in the practice?
• What stakeholders may play a potential role in the practice – directly or indirectly?
• What are the specific target groups for the practice?

WHAT DOES ACTORS AND TARGET GROUPS INCLUDE IN THE ASSESSMENT TOOL?

Practices aimed at promoting diversity management and intercultural communication in the healthcare sector may involve many different actors, target groups and stakeholders. Actors and target groups may not cover each other, and in some cases, it may even be important to differentiate actors and target groups. Thus, it is a good idea to reflect on the different roles and positions that actors, target groups and potential stakeholders are playing, when describing the good practice in the assessment process. It may also include a description of the relationships between actors and target groups in the practice.

ACTORS AND RELATIONS:

The actors in a good practice would refer to all the people directly or indirectly involved in and affected by the practice. This may include professional staff as well as patients in various relational constellations, for instance practices primary involving:

• Healthcare professionals and patients
• Healthcare professionals and relatives
• Heathcare professionals and healthcare professionals in terms of management and staff or in terms of collegiate groups
• Patients and relatives etc.

TARGET GROUPS:

Target groups would be defined as the citizens who are specifically covered by the new practice, who will benefit from the changes  and improvements that are implemented through the new practice. New information materials and brochures in different languages would be a good practice example, where citizens with a particular linguistic-cultural background gain the opportunity to read about patients’ rights and practical procedures for hospitalization in their mother tongue.

HERE WE ASK QUESTIONS LIKE:

• What are the actors and relations involved in the practice?
• What stakeholders may play a potential role in the practice – directly or indirectly?
• What are the specific target groups for the practice?

WHAT DOES AIMS AND OBJECTIVES INCLUDE IN THE ASSESSMENT TOOL?

One basic part of the assessment process is the description of the overall aims and the concrete objectives of the good practice. The more precise aims and objectives are described, the easier it is to carry out the further analysis of good practice achievements. Generally, the overall aims are referring to an overall political-strategic level, whereas the objectives are referring to the implementing-strategic level, where suitable activities and methods are selected for the achievement of the overall aims. Thus, aims and objectives are closely linked and interrelated. But in the description they may seem quite different.

OVERALL AIMS OF THE PRACTICE:

• The overall aims usually have a long-term perspective. Generally, overall aims also correspond with political-strategic intentions and principles such as provision of equal access to certain welfare services or improvement of both services and economics through improvement and increased efficiency within certain welfare sectors etc. For instance, the overall aim for a permanent interpreter service in hospitals may

be to ensure equal access for minority groups in terms of all kinds of treatment in the hospital sector. An overall aim may also be the shortening of waiting times for certain operations through an enhanced cooperation between local GPs and hospital authorities.

OBJECTIVES OF THE PRACTICE:

• The concrete objectives refer more directly to the activity plan and methods used to achieve the overall aims, thus operating on the implementing-strategic level, where the overall aims for the new practice will be realized through new types of activities and methods – and often also through new organizational and cooperative structures. For the compliance of a permanent interpreters corps in all public hospitals, one concrete objective may be to develop a special education for healthcare interpreters in order to ensure adequate professionalism in this new service. Another core objective may be to develop new organizational procedures for the involvement of relevant interpreters in all situations, where patients and relatives in hospitals require an interpretation service.

HERE WE ASK QUESTIONS LIKE:

• What theoretical-methodical approach is used in the practice?
• What concrete activities are implemented and how?
• What methods used are supporting the activities and why? 

WHAT DOES APPROACH, ACTIVITIES AND METHODS INCLUDE IN THE ASSESSMENT TOOL?

The theoretical-methodical approach and the choice of activities and methods used would in the good practice be closely linked to and derived from the objectives of the practice.

THEORETICAL-METHODICAL APPROACH:

The theoretical-methodical approach can be defined as the programme theory for the good practice, linking the practice to the overall aim and objectives as well as to the current professional context. Furthermore, the theoretical-methodical approach describes why the new activities and procedures are considered to be the best methodical way to achieve the results.

ACTIVITIES AND METHODS USED:

In terms of activities and methods used, on example may be that the establishment of a new interpreters corps may start with a research of existing interpreting agencies and the possibilities to cooperate with external interpreters on a permanent interpreter solution in a hospital or in a local health center.

A further activity may be the establishment of an in-house interpreters corps, where the hospital or the health center provides its own corps and the costs linked to the in-house provision.

Finally, a new methodical step may consists of the development of an innovative model where interpreters simultaneously function as a kind of hospital mentors for migrant and immigrant patients with communicative challenges.

HERE WE ASK QUESTIONS LIKE:

• What is the difference between results, effect and impact?
• Why do we operate with this distinction and different assessment levels?
• What focus and perspectives are characteristic for each assessment level?
• How do the assessment levels complement each other?

HOW DO WE DEFINE RESULTS, EFFECT AND IMPACT IN A GOOD PRACTICE?

In the assessment of good practice, we distinguish between results, effect and impact in order to analyze and clarify:

• The result level: whether and to what extent the new practice meets the aims and objectives
• The effect level: whether the new practice leads to the intended effect – or possibly to other positive and relevant side effects
• The impact level: how and by what means – the socalled effective mechanisms – the new practice functions and lead to the intended effect

The basic idea in the good practice assessment tool is that the assessment levels of results, effect and impact complement each other and provide us with a nuanced and operational insight into the strength and sustainability of change in good practices.  By combining the assessment of these three levels, we can achieve a detailed picture of the results and changes caused by the new practice. Furthermore, we can achieve a concrete and transferable understanding of the activities and methods that effectively support and promote the intended results and changes in the particular context and for the particular target groups. We can even learn what does not work, and what we currently need to adjust in order to achieve the good practice effect and results.

THE RESULT LEVEL IN THE GOOD PRACTICE ASSESSMENT

When focusing on the result level, we are checking whether the initial aims and objectives for the new practice are actually met through the implementation of the practice.

THE TIME PERSPECTIVE IN THE RESULT ASSESSMENT:

In general, it makes most sense to conduct the result assessment, when the new practice has been used over a longer period of time. This is especially true for long-term projects and practices with long-term aims and several objectives to be proven and fulfilled. However, sometimes it may be a good idea to conduct a regular monitoring and take samples in order to check, whether the practice is on the right course, and whether it is likely to succeed according to the aims and objectives.

EXAMPLE:

THE EFFECT LEVEL IN THE GOOD PRACTICE ASSESSMENT

By focusing on the effect, we are analyzing, whether the new practice lead to the intended change and improvement in terms of innovation, needs and requirements in a certain target group, in a certain institutional and organizational context, in the mindset, attitudes and competence level of a groups of professionals etc. By assessing the effect, we move a step further from the fulfillment of aims and objectives and focus on the evidence and sustainability of change.

THE TIME PERSPECTIVE IN THE EFFECT ASSESSMENT:

In many cases, it may take quite a long time, before a certain effect takes hold and becomes evident. Thus, effect measurements are often long-term. Still, it is relevant to check on signs of effect regularly in order to verify that the activities and methods used in the practice can produce the intended effect on a long-term basis.

EXAMPLE:

THE IMPACT LEVEL IN THE GOOD PRACTICE ASSESSMENT

By focusing on the impact, we are analyzing, how and why the activities and methods used in the new practice are actually supporting and promoting the intended effect and results. By assessing the impact, we figuratively put a “magnifying glass” on to the practice its the implementation process. Thus, by a close analysis, we examine the relationship and causal links between the applied activities and methods on the one hand – and on the other hand, the preconditions, needs requirements and changing reaction patterns in the target groups affected by the new practice.

The impact assessment builds on the analysis of the socalled effective mechanisms. These are the activities, methods and processes that particularly support and sustain the achievement of the intended results and effects. When focusing on the effective mechanisms in a new practice, we examine how and why the practice functions for the specific target group and specific context.

We may for instance ask: why are the diabetes 2 patients from ethnic minority communities affected by the community-based workshops in a way that make them change their lifestyle and eating habits and their trust in the advice from local GPs.

One effective mechanism may be the cooperation and presence of local community authorities in the campaign workshops.   

Another effective mechanism may be the campaign’s ability to bridge the gap between traditional habits and new, healthier dietary proposals.

THE TIME PERSPECTIVE IN THE IMPACT ASSESSMENT:

The impact assessment should be be carried out regularly in order to ensure that hampering factors and conditions are adjusted or removed as soon as possible. This may for instance be wrong methods or organizational structures that counteract the good practice. Often, such conditions are not visible from the very beginning of a new practice. They only appear when the ongoing impact assessment reveals, to what extent, how and why the new practice fails to provide the proper results and effect. The process analysis of the impact and effective mechanisms will help to identify the counteracting factors.

HERE WE ASK QUESTIONS LIKE:

• What is the link between success indicators and aims and objectives?
• What could be success indicators for results in healthcare good practice?
• What could be success indicators for effect in healthcare good practice?
• What could be success indicators for impact in healthcare good practice?

THE LINK BETWEEN SUCCESS INDICATORS, AIMS AND OBJECTIVES FOR AT GOOD PRACTICE

The success indicators are the factors indicating that the aims and objectives are achieved. The success indicators can be defined as the measurement system in the assessment tool. By assessing the fulfillment of the success indicators, we can conclude whether the new practice is actually leading to the intended results and effect – and furthermore, what are the specific effective mechanisms behind the results and effect.

GENERAL SUCCESS INDICATORS FOR DIVERSITY AND INTERCULTURAL SKILLS IN HEALTHCARE

In terms of aims and objectives for diversity management and intercultural skills in the healthcare services, the success indicators may refer to practices on different levels in the total healthcare sector:

• A political level and changes in legal framework for general improvement of equality treatment and anti-discrimination, thus directly or indirectly improving the framework conditions for diversity management and intercultural communication in healthcare institutions
• An institutional level and changes in the organizational framework to support and promote diversity procedures
• A competence level and changes in professional skills as well as values, beliefs and attitudes to implement diversity and intercultural understanding in healthcare staff and daily practices

Even though the success indicators should be derived from the aims and objectives for the specific practice, target group and context, thuswe set a number of success indicators that may be particularly relevant for the strengthening of diversity and interculturalism in the healthcare sector. These examples can be seen as a supporting tool to define success indicators, when healthcare professionals wish to develop and implement a new good practice to improve diversity management and intercultural skills in the healthcare sector.

MEASURABILITY AND MEASUREMENT DATA AND METHODS

Success indicators can refer to quantitative as well as qualitative measures. The general rule is that success indicators have to be measurable one way or the other. Therefore, when setting indicators, we also have to ask: what kind of data are suitable for the measurement, and what kind of data may otherwise illuminate the indicators?  

METHODICAL TRIANGULATION:

Sometimes it is necessary to put forward very quantitatively measurable figures like the number or percentage of a certain target group changing their behaviour in a certain way – like the diabetes 2 patients in the previous assessment example. Other times we have to use more qualitative and interpretative measures. If we ask the diabetes 2 patients about their personal experience of the new diets, then their subjective answers would call for an interpretation, even though we may be able to quantify the answers from a major group of diabetes 2 patients who joined the special campaign. Generally, when dealing with the implementation of major projects and new practices, we need to use various data and measurements to assess the results as well as the effect and impact on a short-term and a long-term basis. Therefore, it is advisable to operate with methodical triangulation, which basicly means a combination of different data sources and measurement methods. By examining the results, effect and impact from various data sources and methods we can ensure a better validity and evidence in the assessment conclusions and recommendations. Data sources may be:

SUCCESS INDICATORS FOR GOOD PRACTICE RESULTS

Using the previous example of a result assessment linked to the healthcare sector, we could add a number of success indicators:

Other examples of success indicators for results in healthcare good practice:

The good practice results in healthcare services may be:

• Dissemination of code of conduct for intercultural understanding and communication in an increased number of healthcare institutions from both the primary and secondary healthcare sector
• Equal access to healthcare education and employment through new methods to diversity recruitment to healthcare professions and services
• New organizational structures and procedures for medical assessment of patients with migrant/ethnic minority background
• Permanent interpreter services with fixed rules for summoning and involvement of interpreters in all hospital wards
• New institutional framework for formal cooperation between patients, relatives and healthcare professionals
• Improved access to various healthcare services in practice for migrant/ethnic minority citizens and users
• Decline in the share of both formal and experienced discrimination among migrant/ethnic minority healthcare professionals in the daily job performance etc.

SUCCESS INDICATORS FOR GOOD PRACTICE EFFECT

Using the previous example of an effect assessment linked to the healthcare sector, we could add a number of success indicators:

Other examples of success indicators for effect in healthcare good practice:

Good practice effect in healthcare services may be:

• A decrease in short-term hospitalization among migrant/ethnic minority patients, due to more efficient medical assessments based on intercultural understanding
• Better insight into and involvement of Non-Western treatment systems and practices among healthcare professionals, due to a systematic intercultural training
• Higher cure rate among migrants/ethnic minorities, due to early preventive efforts in local communities and due to a systematic cooperation between public, private and voluntary healthcare actors and stakeholders
• Permanent interpreter services with fixed rules for summoning and involvement of interpreters in all hospital wards
• New institutional framework for formal cooperation between patients, relatives and healthcare professionals
• Improved access to various healthcare services in practice for migrant/ethnic minority citizens and users
• Better physical and mental well-being and greater confidence in the healthcare system among migrant/ethnic minority citizens and patients
• Decline in the share of both formal and experienced discrimination among migrant/ethnic minority healthcare professionals in the daily job performance etc.

HERE WE ASK QUESTIONS LIKE:

• What frame conditions are needed to implement this practice?
• What skills and competences must be present in order to implement and anchor the practice?
• What special attention points should be observed and recommended in a transfer process?

WHAT COULD BE RELEVANT FRAMEWORK CONDITIONS?

When transferring a good practice from one context to another, it is very important to be aware of the specific framework conditions that has characterized the initial context. Although the good practice was developed and implemented in a similar context – for instance in a certain hospital ward – the contextual framework may be quite different on closer inspection. This is why the contextual analysis of framework conditions is very important before the transference of a good practice from one healthcare context to another. 

It is noteworthy that the structural and institutional framework conditions may vary quite dramatically even within the same types and areas of healthcare service – especially across national borders. For instance, the economic framework for hospital operation may differ and follow very different legal rules and procedures. The same will apply to other forms of financing such as the use of private funding etc. Furthermore, the organizational opportunities to implement new practices will be different both within and across national borders. Management support and organizational adaptability as well as motivation and readiness for changes in working methods are framework conditions of great importance for the successful implementation of a new practice.

Any attempt to transfer a good practice from one healthcare context to another should take such framework varieties into careful considerations:

• What are the financial basis for the good practice – what expenditures and financial sources are included in the budgeting?
• How is the good practice managed and organized – is the good practice project-based or fully incorporated in the ordinary organization?
• Will all staff members benefit from the good practice – or would there be disadvantages for some employees?