Form 10 Cultural Competency

HRSA Patient Navigator Demonstration Program

CULTURAL COMPETENCY CHECKLIST

Section A: Overview

The purpose of the Patient Navigator Cultural Competency Checklist is to help identify when Patient Navigators (PN) are not meeting standards so that PN Supervisors can help them improve their navigation skills and to measure the influence of PN performance on patient outcomes.

Section B: Administration

This Checklist is to be completed on each PN by the PN Supervisor at their PNP site. To complete this Checklist, the Supervisor will (1) observe the PN during a Navigator-Patient encounter and (2) review the PN’s written/entered documentation of the observed encounter in order to evaluate accuracy and timeliness of documentation.

The Cultural Competency Checklist will be completed on each PN at least two (2) times per year.

Section C: PNDP Patient Navigator Performance Checklist

The Checklist addresses four areas:

1. Client Interaction

2. Care Management

3. Intervention (Patient Navigator)

4. Documentation

Each area has a description of components (i.e., Quality) of the item with specified related criteria for evaluating performance.

Each of the four areas are scored as follows:

2 = Meets Expectations

1 = Needs Improvement, any single criteria not met

0 = Unacceptable, two or more criteria not met.

Additional space on the checklist is provided for Supervisor comments.

NOTE: The completed Cultural Competency Checklist form will not be submitted to the PNP online database. Only variables and scores (shown in Table X) will be sent to the database.

Section D: Patient Navigator Cultural Competency Checklist Form

The Cultural Competency Checklist form is provided on the following page. PN Supervisors will need to record their assessment either manually or electronically. Supervisors will be instructed by their Project leadership which method to use.

PNDP Navigator Cultural Competency Checklist

Date:

Patient Navigator Name: Supervisor Name:

Encounter Type (in-person, telephone, etc): Encounter Length (minutes):

Description of Interaction:

Quality	Criteria	Score	Comments
I. Client Interaction Established rapport and a therapeutic relationship.	1a. Communicated respect, warmth, and concern. 1b. Formed a partnership within professional boundaries.	_____________ 2= Meets Expectations 1= Needs Improvement, any single criteria not met 0= Unacceptable, two or more criteria not met
(first visit) Oriented the client to the agency/program.	2a. (first visit) Explained the purpose of the agency/program, described policies and the services provided. 2b. (first visit) Provided names and roles of key personnel and contact information.
Communicated in an understandable manner and monitored client’s understanding.	3a. Assessed the need for an interpreter; obtained and utilized one if necessary. 3b. Spoke clearly and slowly in conversational tone, using common words without jargon. Used open-ended questions, paraphrasing, and summarization. 3c. Asked client for questions and answered them accurately or told client they would get answer.
II. Care Management Assessed/Reassessed patient needs.	1. Assisted client to identify needs and concerns.	_____________ 2= Meets Expectations 1= Needs Improvement, any single criteria not met 0= Unacceptable, one or more criteria not met
Obtained and used knowledge of client’s cultural, ethnic, religious, and social systems to develop and revise care/action plan.	2. Inquired about client’s perceptions, cultural, ethnic, religious and social beliefs, and values.
Appropriately identified barriers to care.	3a. Articulated and confirmed barriers to care and their order of priority with client. 3b. Engaged the client in goal setting and establishing plan.
Assisted client in assuming responsibility for execution of plan to reduce barriers.	4. Collaboratively determined actions to reduce barriers and who would do what, by when.
Arranged follow-up.	5. Set appointment for next contact.
III. Intervention Provided client with factual and appropriate information and education (including materials).	1a. Used visual, auditory and experiential modes of presenting information and education. 1b. Information and education addressed client’s needs and concerns and was correct.	_____________ 2= Meets Expectations 1= Needs Improvement, any single criteria not met 0= Unacceptable, two or more criteria not met
Referred and assisted client to access needed resources to meet identified needs.	2a. Provided referral(s), explained purpose and how to access. 2b. Assisted client in completing paperwork and applications.
IV. Documentation Data is accurate, complete, and entered within 24 hours of client interaction.	1a. Data is accurate. 1b. Data is complete. 1c. Data is entered within 24 hours of client interaction.	_____________ 2= Meets Expectations 1= Needs Improvement, any single criteria not met 0= Unacceptable, two or more criteria not met
Overall Rating Category 7-8= Meets Expectations 5-6= Needs Improvement 0-4= Unacceptable		Total Score ________

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