Table 1.

NQF cultural competency domains, CCATH subdomains, and CLAS standards

NQF domains	CCATH subdomains	CLAS standards
Leadership	Leadership and strategic planning	8. HCOs should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability or oversight mechanisms to provide CLAS.
		14. HCOs 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 communities about the availability of this information.
Integration into management systems and operations	Data collection on inpatient population	10. HCOs should ensure that data on the individual patient’s or consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated.
	Data collection on service area	11. HCOs 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.
	Performance management systems and QI	9. HCOs should conduct initial and ongoing organizational self-assessments 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 outcome-based evaluations.
Workforce diversity and training	Human resources practices	2. HCOs 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.
	Diversity training	3. HCOs should ensure that staff at all levels and across all disciplines receive ongoing education and training in CLAS delivery.
		13. HCOs 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 or consumers.
Community engagement	Community representation	12. HCOs 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 activities.
Patient–provider communication	Availability of interpreter services	4. HCOs must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient or consumer with LEP at all points of contact, in a timely manner during all hours of operation.
	Interpreter services policies	5. HCOs must offer and provide to patients or consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.
	Quality of interpreter services	6. HCOs must assure the competence of language assistance provided to limited English proficient patients or consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient or consumer).
	Translation of written materials	7. HCOs 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 service area.
Care delivery and supporting mechanisms	Clinical cultural competency practices	1. HCOs should ensure that patients or 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.