STARBURST MEDICAL CENTER

Cultural competence and diversity

plan
PURPOSE
Implementation of department response to the changing needs and expectations of
every person entering our organization. The development and implementation of the
plan to ensure our staff are sensitive and aware of the various moral values and diversity
of the community that we serve.
SCOPE
A. This policy applies to all organizations employees, management, contractors,
student interns, and volunteers.
B. This policy describes the organizations objectives and policies regarding maintaining
the treatment and respect of every person that enters our facilities.
DEFINITIONS
Term: Diversity
Definition: Culture, age, gender, sexual orientation, spiritual beliefs, socioeconomic
status, and language
Term: Competency
Definition: Awareness of, respect for, and attention to diversity of our patients
Term: Values
Definition: Principles set to do what is right
Term: Bias
Definition: Prevents impartial judgement
RESPONSIBILITIES
Management
1)
2)
3)
4)

Establish program objectives

Approve training plan
Provide training for work force
Assign a Patient Advocate

Patient Advocate
1) Develops policies and procedures to ensure that patients receive their medical
information in their preferred language
2) Coordinates and implements policy through organizations departments
3) Oversees training
4) Receives and processes privacy complaints
Supervisor, Training
1) Implements diversity training program
2) Define diversity beyond race/ethnicity
3) Share success stories
Employee responsibilities
1) Understand and comply with organizations policies regarding patient needs
ECOURAGEMENTS FOR PERSONAL PRACTICES WITHIN THE DEPARTMENT
1) Use of translating features on the internet
2) Assess the impact of biases and its relationship to the quality of care
3) Commitment to utilization of assessment tools that include appropriate questions
that may be sensitive to different cultures
INTREPRETERS
1) Documentation on the EHR that pertains to what language the patient wants their
medical information conveyed
2) If patient states they would like for their medical record to be supplied by a
language other than English, there must be a certified interpreter provided
3) The department must make a best effort attempt to provide an interpreter from
a certified agency
4) If there is not an interpreter provided, then the department must use the services
of an over-the-phone interpreter
a. Use and/or interpreting services
i. Contact interpreting agency through the facility operator
ii. Interpreters agency, name, and employee number must be
documented each procedure in the EHR
BROCHURES/LITATURE
5) Health Insurance Probability and Accountability Act (HIPAA) provided in multiple
languages, including Braille
6) Financial Assistance provided in multiple languages, including Braille
7) General Consent Forms provided in multiple languages, including Braille

HIPPA Privacy Policy

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INDIVIDUAL RIGHTS
1
2
3

Right to have their medical information conveyed in a language the patient

prefers
Right to file a complaint
Right to receive a reply to a complaint in a timely manner

WORK FORCE TRAINING

1

Training on cultural competence and diversity

a. New staff member training: Every staff member will receive initial training
during employee orientation
b. Recurrent training: Every year training video seen through SMC website with
the passing score of a test after the video. Staff must be committed to lifelong
learning to be current with new technology and resources

EMPLOYEE COMPLAINTS
1
2

Patient Advocate can be reached through the facilitys operator

All complaints will be answered in a timely manner

SANCTIONS
1

Violation of policy would result in termination of employment

HIPPA Privacy Policy

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