How Healthcare Organizations Characterize Minority Health Programs: A Comparative Analysis of Diversity Responsiveness Frameworks

Background

Health disparities are a persistent and critical issue within healthcare systems globally. As patient populations become increasingly diverse, healthcare organizations face the imperative to adapt and become more responsive to the unique needs of minority groups. These disparities, often manifesting as poorer care for individuals from minority ethnic backgrounds or migrant communities compared to majority populations, are extensively documented across nations, including the United States and increasingly in Europe and Australia. Addressing these inequalities necessitates a multifaceted approach, involving interventions at the individual caregiver, organizational, and systemic levels. While individual-level interventions focus on enhancing the knowledge, skills, and attitudes of healthcare providers, organizational responsiveness demands the implementation of specific service policies and practices. System-level changes encompass broader measures, such as legislative actions ensuring equitable financial access to healthcare.

In the United States, the cultivation of organizational responsiveness has been significantly influenced by the CLAS (Culturally and Linguistically Appropriate Services) standards. These standards are designed to mitigate disparities experienced by racial, ethnic, and linguistic minority groups. Across Europe, similar initiatives promoting diversity responsiveness emerge under various labels, including ‘migrant-friendliness,’ ‘intercultural opening,’ ‘transcultural competence,’ and ‘difference sensitivity,’ often targeting a broader spectrum of vulnerable groups that extend beyond ethnic and cultural minorities.

The concept of ‘cultural competence’ has been central to discussions around responsiveness to ethnic and cultural diversity for decades. However, the term has faced criticism for its potentially narrow operationalization, sometimes overemphasizing expert knowledge about specific minority groups. Critics argue this focus can lead to stereotyping and an undue emphasis on the ‘otherness’ of patients. Despite these critiques, many cultural competence frameworks adopt a more comprehensive approach, highlighting the importance of a triad of skills, attitudes, and knowledge.

The development of consistent terminology and definitions is crucial for the advancement, implementation, and evaluation of diversity-responsive healthcare practices grounded in evidence. This study undertakes a qualitative analysis and comparison of six prominent approaches to organizational diversity responsiveness in healthcare. Our investigation seeks to determine whether the terminological variations across these approaches reflect substantial differences in their core content, or if there is a fundamental consensus regarding the measures organizations should adopt to tailor health services to diverse patient populations. This paper aims to answer the following key questions:

1. What are the primary domains of health service provision emphasized by these approaches?
2. To what extent is there agreement across these approaches regarding these critical domains?
3. What are the most consistently recommended elements for healthcare organizations to prioritize to enhance their responsiveness to diversity?

Method

Sampling Strategy of Approaches

Recognizing the proliferation of guidelines and recommendations for enhancing organizational responsiveness to diversity from both public and private entities internationally, this study did not aim for an exhaustive review. Instead, we employed a purposive sampling strategy to select six influential approaches to diversity responsiveness at the organizational level. The selection criteria were designed to ensure the inclusion of impactful and widely applicable frameworks:

• Broad Applicability: The approach was designed for use beyond a single local healthcare organization, targeting wider implementation.
• Authoritative Source: Developed by a recognized public body, such as a health ministry or a distinguished expert group, lending credibility and authority.
• Public Accessibility: The approach was publicly available, ensuring transparency and ease of access for organizations and researchers.
• Geographical Diversity: The final selection included approaches from the United States, Australia, and Europe, capturing a range of perspectives and healthcare contexts.

We began with the CLAS Standards as a foundational approach and iteratively added others through searches of published and grey literature until we reached saturation, meaning no new significant information emerged from adding further approaches. This sampling process was conducted in 2012.

The six approaches selected for analysis are:

1. CLAS Standards – National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS), developed by the Office of Minority Health, U.S. Department of Health and Human Services.
2. Advancing Effective Communication, Cultural Competence, and Patient- and Family Centered Care: A Roadmap for Hospitals (JCR), developed by the US Joint Commission.
3. Cultural Responsiveness Framework. Guidelines for Victorian health services (CRF), developed by the Victorian Government, Department of Health, Australia.
4. Recommendation of the committee of ministers to member states on mobility, migration and access to health care (COER) of the Council of Europe.
5. The Equality Delivery System (EDS) for the NHS, UK.
6. Standards for Equity in Health Care for Migrants and other Vulnerable Groups (EQS) developed by the WHO-HPH Task Force on Migrant-Friendly and Culturally Competent Healthcare.

Table 1 provides a detailed description of each approach and the rationale for its inclusion in this study.

Table 1. Description of the six approaches on responsive health care that were included

1. CLAS Standards – National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) [ 9 ]. These standards were developed by the Office of Minority Health, part of the U.S. Department of Health and Human Services. Some of the standards have the status of mandates, meaning that they are Federal requirements for all health care organizations that receive Federal funds; others are purely recommendations. We included the CLAS standards because they were the first one and probably the most comprehensive and influential approach currently in use. In May 2013 the Enhanced CLAS Standards were published [ 11 ]. Although largely similar, there are some differences of emphasis between the original and the Enhanced CLAS Standards:
• The revised CLAS acknowledged that in order to address disparities in health care (for any target group), we need to go beyond cultural issues and deal with other (e.g., social, psychological) issues.
• In the vision on responsive care some slight changes of emphasis could be found, such as a shift from regarding diversity as a ‘group’ characteristic to ‘appreciating the diversity of individuals’. The enhanced CLAS also places more emphasis on the importance of ‘patient- and family centred care’, thus bringing it more into line with the JC Roadmap.
2. Advancing Effective Communication, Cultural Competence, and Patient- and Family Centered Care: A Roadmap for Hospitals (JCR) [ 20 ]. This ‘Roadmap’ has been developed by the Joint Commission (JC), an independent, not-for-profit organization which accredits and certifies health care organizations in the United States. The Roadmap was developed in addition to existing JC requirements “to inspire hospitals to integrate concepts from the fields of communication, cultural competence, and patient- and family-centered care into their organizations.” We included the JC Roadmap because of the global influence of JC and the Joint Commission International (JCI) accreditation program on health care organizations through their accreditation programs (applied in over 50 countries). JC developed its own framework of recommendations in which cultural competence is embedded within effective communication and patient- and family centred care. Please note that 1) other existing JC requirements also include issues related to those issues discussed in the Roadmap, and 2) that the national Joint Commission Standards are different from the Standards of the Joint Commission International.
3. Cultural Responsiveness Framework. Guidelines for Victorian health services (CRF) by the Rural and Regional Health and Aged Care Services, Victorian Government, Department of Health (Australia) [ 21 ]. The CRF was developed to replace the Health Service Cultural Diversity Plans (HSCDPs) which since 2006 have required all Victorian health services to develop and implement policies for ethnic diversity in care. The intention of the CRF is to consolidate multiple requirements for reporting on cultural diversity initiatives within health services. All Victorian health services are required to submit plans and achievements according to the standards and measures in the CRF to the Statewide Quality Branch. We included the CRF because it has been disseminated and made compulsory in a large health care system in Australia.
4. Recommendation of the committee of ministers to member states on mobility, migration and access to health care (COER) of the Council of Europe [ 22 , 23 ]. The Council of Europe is an international organization set up “to achieve a greater unity between its members for the purpose of safeguarding and realizing the ideals and principles which are their common heritage and facilitating their economic and social progress” [ 37 ]. We included the COER because it has been endorsed by the Health Ministers of the 47 member states of the Council of Europe. The document is aimed at ministerial level, therefore it includes recommendations that have consequences for the whole health system. These recommendations focus on the diversity responsiveness in the context of migrants and their children. To make comparisons possible we have only included the recommendations at organizational level in our analysis.
5. Equality Delivery System (EDS) for the NHS [ 24 ]. EDS originates from the Equality and Diversity Council within the British National Health Service (NHS). It is designed to help NHS organizations to comply with the ‘Public Sector Equality Duty’ (PSED) of the Equality Act. This act “requires public bodies to consider all individuals when carrying out their day to day work – in shaping policy, in delivering services and in relation to their own employees” [ 38 ]. EDS is made available to the NHS as an optional tool. It was included because it is a European instrument which has been disseminated in a large health care system.
6. Equity Standards (EQS) of the Task Force on Migrant-Friendly and Culturally Competent Healthcare [ 25 ]. These Standards were developed by a group of mainly European experts set up within WHO’s Health Promoting Hospitals network. The Equity Standards are a self-assessment instrument to enable health care organizations to carry out an ‘equity evaluation’ against a set of standards. The instrument was piloted in 10 European countries, as well as in two non-European ones. The Equity Standards were included because of the broad international context in which they were developed.

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It is important to note that while the Enhanced CLAS Standards were published in May 2013, this analysis uses the original CLAS Standards. The rationale for this is that the original CLAS was considered the most historically significant and influential approach, and the revisions in the enhanced version were not deemed fundamentally different in their underlying approach. The enhanced version primarily aimed to clarify the standards, reflect recent developments, and align with initiatives like the Affordable Care Act and the Joint Commission’s work, rather than to introduce a new conceptual framework.

Developing an Analytical Framework for the Present Analysis

Encoding of Content

The development of the analytical framework for this study involved a systematic and iterative process of qualitative textual analysis:

1. Inductive Approach with CLAS: We began with an inductive approach, initially analyzing the CLAS Standards. The 14 CLAS standards were grouped into conceptually distinct topic areas, which we defined as domains. Within each domain, we then identified dimensions that represented the concrete operationalization of the domain’s concept within the CLAS framework.
2. Iterative Application and Expansion: A second approach (JCR) was selected, and its content was analyzed and categorized using the domains and dimensions identified in Step 1. Where the JCR content extended beyond the existing framework, new dimensions or domains were created to accommodate these novel aspects.
3. Sequential Analysis of Remaining Approaches: The remaining four approaches (CRF, COER, EDS, and EQS) were analyzed sequentially, each time refining the framework by adding new dimensions or domains as needed to comprehensively capture the content of each approach.
4. Framework Review and Consensus: The resulting framework of domains and dimensions was critically reviewed and discussed among three authors (MCS, MLE-B, and JDI) to ensure clarity, eliminate ambiguities, and resolve any overlaps between categories. This iterative discussion process continued until a consensus was reached on the final structure and definitions of the domains and dimensions.

Comparison of Content

The analytical framework, comprised of domains and dimensions, provided a structured matrix for comparing the content of the six approaches. This framework allowed for a systematic ‘at-a-glance’ comparison, highlighting both unique and absent domains across different approaches. Within each domain, the framework facilitated the identification of variations in how each approach operationalized responsiveness. The analysis focused on documenting both the commonalities and differences between the approaches. MCS conducted the primary analysis, and MLE-B and JDI independently reviewed the results. Disagreements were resolved through discussion to ensure the robustness and reliability of the comparative analysis.

Ethics statement

This research involved the analysis of publicly available documents and did not involve human subjects or personal data. Therefore, an ethics statement was not required for this study.

Results

This section presents the findings of our comparative analysis. We begin with background information on each of the six approaches. Following this, we provide a detailed overview and analysis of their content, organized according to the domains and dimensions of our analytical framework. Finally, we summarize the key similarities and differences identified across the six approaches.

Background Information

Table 2 provides a concise summary of background information for each of the six approaches, including their acronyms, origin, year of publication, aims, vision, target population, target organization type, and structure.

Table 2. Background information on the six approaches

Background information on model	CLAS Standards (CLAS)	Joint Commission Roadmap (JCR)	Cultural Responsiveness Framework (CRF)	Council of Europe Recommendations (COER)	Equality Delivery System (EDS)	Equity Standards (EQS)
origin	US dept of Health and Human Services; Office of Minority health (U.S.)	The Joint Commission (U.S.)	Victorian Government; Dept. of Health (Australia)	Council of Europe; The committee of ministers (Europe)	The National Health Services (NHS); The Equality and Diversity Council (U.K.)	Health Promoting Hospitals; Task Force on Migrant-Friendly and Culturally Competent Health care (Europe)
year	2001	2010	2009	2011	2011	2013
aim	*ensure equitable and effective treatment in a culturally and linguistically appropriate manner*correct inequities*more responsive services*elimination of racial and ethnic health disparities*inform, guide and facilitate culturally and linguistically appropriate care	*improve overall safety and quality of care*integrate concepts from communication, cultural competence and patient-centered care fields into hospitals	*better links between access, equity, quality and safety*better health outcomes for culturally and linguistically diverse (CALD) populations*enhance cost effectiveness of service provision*track organizations’ improvement; align cultural responsiveness (CR) with existing standards; develop benchmarks	*Equitable access to health care of appropriate quality	*better outcomes for patients and communities, better working environments for staff*improve equality performance*review equality performance*a tool to comply to the ‘public sector Equality Duty’.	*ensure equitable and accessible health care *reduce disparity in health care*an Equity self-assessment by health care organizations
vision	*cultural and linguistic competence*culturally and linguistically appropriate services (CLAS)	*effective communication (EC)*cultural competence (CC)*patient- and family-centered care (PFCC)	*cultural responsiveness (CR)	*improving the adaptation of health service provision to the needs, culture and social situation of migrants	*equality for patients and staff*personal, fair and diverse services and workplaces	*promoting equity
target population	*inclusive of all patients*especially racial, ethnic, and linguistic populations that experience unequal access	*no target group, recommendations address ‘issues’ in health care (e.g. language, culture etc.)	*Culturally and linguistically diverse populations (CALD)	*migrants	*protected groups	*migrants and all other vulnerable groups
target organization-type	*health care organizations*policymakers, accreditation agencies, purchasers, patients, advocates, educators, health care community in general	*hospitals	*all Victorian health services	*governments of CoE member states	*NHS commissioners and providers	*health care organizations
structure	*14 standards in three types: mandates (4), guidelines (9), and recommendations (1)*three themes: culturally competent care, language access services, and organizational supports for cultural competence	*54 recommendations structured around main points along the care continuum*aspects of the care continuum: admission; assessment; treatment; end of life care; discharge and transfer; organization readiness	*six standards across four domains, divided in measures and sub-measures (both quantitative and qualitative)*Standards: a whole organization approach; leadership; interpreters; inclusive practice; consumer/community involvement; staff.*Four domains: organizational effectiveness; risk management; consumer participation; effective workforce	*14 recommendations, specified in 31 sub-recommendations.	*18 outcomes grouped into four goals; nine steps for implementation*EDS goals: better health outcomes for all; improved patient access and experience; empowered, engaged, and well-supported staff; inclusive leadership at all levels	*five main standards, divided in substandards and measurable elements *main standards: equity in policy; equitable access and utilization; equitable quality of care; equity in participation; promoting equity

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The aims of these approaches commonly revolve around reducing or eliminating health and service provision inequalities between different populations (CLAS, COER, EQS), and enhancing outcomes for individual patients (JCR, CRF, EDS). Approaches like CLAS, COER, and EQS are rooted in human rights principles, viewing group-based inequalities as injustices requiring rectification. JCR frames patient outcome equality as a performance metric, while CRF and EDS integrate both perspectives. Notably, CRF uniquely aims to improve the cost-effectiveness of healthcare delivery, and EDS seeks to foster better working environments for staff.

Regarding the vision of responsive care, ‘cultural competence’ is explicitly referenced by CLAS, JCR, and CRF. CLAS adopts a classic definition of cultural competence and underscores language access. JCR integrates cultural competence as a core concept alongside effective communication and patient- and family-centered care. CRF introduces ‘culturally responsive care,’ a concept closely aligned with CLAS and JCR. These three approaches share a common emphasis on ‘culture’ in their conceptualization.

In contrast, COER, EDS, and EQS prioritize ‘equity’ or ‘equality’ over ‘culture.’ COER targets “equitable access to health care of appropriate quality,” emphasizing adapting services to the “needs, culture, and social situation of migrants.” EDS links equality to quality, defined by recognizing the needs of all (patients and staff) and ensuring accessible, appropriate, safe, and effective services. EQS intentionally moves away from ‘cultural competence,’ adopting Whitehead’s equity definition: “equal access to available care for equal need; equal utilization for equal need; equal quality of care for all.”

The target populations vary across approaches. CLAS, JCR, and CRF focus on race, ethnicity, culture, or language. EDS and EQS broaden this to include gender, age, disability, religion, sexual orientation, transgender status, and more (see Table 2). COER uniquely focuses on migrants, a category less explicitly addressed in the others, defining ‘migrant’ broadly to include asylum seekers, refugees, and victims of trafficking, extending to second and later generations and internally displaced persons. This broad definition of ‘migrants’ in COER significantly overlaps with the concept of ‘ethnic minorities’ used in other approaches.

‘Horizontal’ Analysis: Comparison of Domain Content Across Approaches

Organizational Commitment

This domain encompasses elements reflecting management-level commitment to diversity responsiveness. We identified two key dimensions: policy and leadership and measurement of performance.

Policy and Leadership

All six approaches emphasize the necessity of explicit organizational commitment to developing responsive care, moving beyond ad hoc individual efforts to structurally embedded organizational practices. COER implies this through its emphasis on a ‘whole organization approach.’ This commitment can manifest as a formal plan (CLAS, EQS), outlining the organization’s strategy for ensuring responsiveness, a policy of strong leadership (JCR, EDS), or a combination of both (CRF).

‘Good leadership’ is defined by a clear commitment to responsive care and active promotion of this value throughout the organization (JCR, EDS). Leaders are expected to take ownership of achieving responsiveness goals (CRF). All approaches stress integrating diversity responsiveness plans into existing organizational policies and processes. EQS further promotes a ‘proactive’ approach, advocating that all organizational plans should consider their potential impact on access and quality of care for vulnerable groups.

Measuring and Improving Performance

A core tenet across all approaches is the importance of measuring organizational performance in delivering responsive services. This includes assessing treatment outcomes for different groups to identify areas for improvement, implement necessary actions, and track progress in enhancing responsiveness. CLAS, EDS, and EQS specifically highlight the need for continuous performance measurement integrated into regular quality improvement systems. The approaches differ somewhat in the variables recommended for measurement, with some focusing on care quality, others on accessibility, and some on both. (Refer to the ‘collecting data’ domain for data sources). CRF uniquely mandates specific indicators for measuring organizational cultural responsiveness, requiring affiliated organizations to report these for benchmarking purposes.

Collecting Data

This domain focuses on data collection as a means to inform organizations about equitable access and quality of care, and to identify specific needs and improvement opportunities. We distinguish between two types of data: data on the population at large and data on the organization’s own users.

Data on the Population at Large

Five approaches (CLAS, JCR, CRF, EDS, EQS) recommend collecting data on the community or catchment area served to tailor services to identified needs. Organizations are encouraged to utilize existing data sources, but CLAS and EDS also advocate for organizations to actively collect this data themselves. Relevant data includes demographic variables (e.g., age, gender, ethnicity), factors influencing service utilization (e.g., language proficiency, health literacy), health status, and exposure to health risks. COER strongly emphasizes empirical evidence, urging governments to collect data “in partnership with relevant organizations.”

Data on the Patient Population

Patient files are identified as a valuable source of data on ethnicity, race, language, and other characteristics relevant to care quality. CLAS, JCR, CRF, and EQS emphasize the importance of this data for identifying and monitoring health and healthcare inequalities. For CLAS, JCR, and EQS, patient file information on individual characteristics associated with minority status (e.g., proficiency in the majority language) also enables care adaptation at the individual level. Additionally, CLAS, JCR, CRF, EDS, and EQS stress the need for outcome measures and patient feedback systems to analyze results based on diversity characteristics. The approaches vary in the specific types of patient data recommended for collection.

Staff/Workforce

This domain centers on the organization’s staff or workforce, with two primary dimensions: staff competencies and diversity in the workforce.

Staff Competencies

Enhancing staff competencies in delivering responsive care, particularly through education and training, is a central theme across all approaches. CRF and EDS propose comprehensive strategies for improving staff confidence and competence, including personal development programs (EDS) and adapted HRM policies (CRF). CLAS, CRF, COER, and EQS emphasize that training should be provided to all staff members (CLAS extends this to affiliated and subcontracted staff). CLAS, CRF, and EQS also recommend monitoring the effectiveness of training programs. CLAS suggests dedicated training on responsive care delivery, while JCR proposes integrating this training into existing curricula. COER and EQS support both approaches. The level of detail provided regarding training content varies across the approaches.

Diversity in the Workforce

CLAS, JCR, and COER advocate for workforce diversity as a means to enhance responsiveness to patient diversity. Two main rationales are presented: first, the workforce should reflect the general population (CLAS, COER); second, staff diversity can improve equity by facilitating linguistic and ethnic concordance between patients and staff (CLAS, JCR). EDS and EQS address workforce diversity from an equality perspective, focusing on inclusive Human Resource policies related to recruitment and other HR practices. CRF does not explicitly address workforce diversity.

Ensuring Access

This domain encompasses factors that may act as barriers to accessing healthcare organizations. Key dimensions include entitlement to care, provision of understandable information, and geographical and other aspects of accessibility. Some issues within this domain also overlap with ‘care provision’ as they are relevant to the patient-caregiver interaction.

Entitlement to Care

Entitlement to care, specifically insurance status or eligibility for national health services, is not addressed in CLAS, JCR, CRF, or EDS. This is understandable as entitlement is often determined by legislation and insurance regulations, rather than provider policies. However, EQS goes further, assigning organizations a responsibility for patients ineligible for care, urging them to at least facilitate access to care elsewhere. COER, which includes system-level recommendations, advocates for “adequate entitlements to use of health services” and emphasizes the role of providers in ensuring legislative implementation and awareness of patient rights among care providers.

‘Understandable’ Information

CLAS, COER, and EQS highlight the importance of providing ‘understandable’ information to improve accessibility. This includes translated and health literacy-adapted information for targeted populations.

Geographical Accessibility

COER and EQS briefly discuss the significance of reducing geographical barriers to access.

Other Aspects of Accessibility

EDS and EQS introduce unique accessibility dimensions. EDS mentions specific care types like public health, vaccination, and screening programs. EQS addresses the accessibility of organizations for specific ‘disadvantaged’ groups such as HIV/AIDS patients, disabled individuals, and the homeless.

Care Provision

This domain focuses on the quality of care patients receive within healthcare organizations. Key topics across the six approaches include: care responsive to patient needs and wishes, patient participation in care, overcoming communication barriers, providing understandable patient information, trust-building, and patient rights.

Care Responsive to Needs and Wishes

All approaches emphasize the importance of care that is responsive to patient needs and wishes. However, the interpretation of this dimension varies based on each approach’s vision of responsive care:

• CLAS and CRF focus on cultural needs, aligning with their ‘culturally competent’ and ‘culturally responsive’ visions.
• JCR emphasizes integrating ‘additional’ and ‘unique’ needs into the clinical process, considering the “spectrum of each patient’s demographic and personal characteristics.”
• COER focuses on the needs of migrants (broadly defined), extending beyond culture to include social position, migration history, and legal status.
• EDS and EQS emphasize needs arising from patients’ individual characteristics.

Beyond identifying needs, JCR also considers when these needs should be addressed within the care continuum. While all approaches prioritize patient needs and wishes, they acknowledge the professional autonomy of healthcare providers to reconcile patient demands with their professional judgment.

Patient Participation in the Care Process

Five approaches (JCR, CRF, COER, EDS) explicitly mention patient participation or involvement in individual care, such as shared decision-making in treatment and care planning. While CLAS and EQS do not explicitly mention patient participation in this context, their standards imply an understanding of patients as active participants in their care.

Overcoming Communication Barriers in Patient-Provider Contact

All approaches except EDS stress the organizational responsibility to address language barriers in service delivery, providing language assistance when needed. Various interpreting modalities are recommended, including professional interpreters, bilingual staff, or intercultural mediators, with varying preferences. CLAS, JCR, and COER advise against using untrained, informal interpreters like family members. CLAS, JCR, CRF, and EQS emphasize organizational responsibility for ensuring the quality and competence of language assistance. CLAS and JCR recommend informing patients of their right to language assistance. JCR and EQS also address support for patients with other communication barriers like hearing or speech impairments.

Understandable Patient Information Materials

With the exception of EDS, all approaches emphasize the need for patient information materials to be understandable in terms of language and health literacy. When suitable materials are unavailable, CLAS asserts the right to orally translated information. This applies not only to medical information leaflets but also to consent forms and medication labels.

Trust

The approaches address several aspects of building trust between service users and providers. This includes creating a welcoming and inclusive organizational environment (CLAS, JCR, EQS). Some approaches emphasize patient safety, ensuring protection from mistreatment arising from vulnerability. Phrases used include “patients are free from abuse, harassment, bullying, violence” (EDS) and “the patient has the right to be free from neglect, exploitation, and verbal, mental, physical and sexual abuse” (JC Requirements).

Conflict and grievance procedures are also linked to trust. CLAS and JCR recommend that these procedures should be equipped to identify and address issues related to diversity responsiveness, handling conflicts respectfully (CLAS, JCR, EDS). Access to grievance procedures for minority patients is also highlighted (CLAS, JCR), including the need for trained personnel to handle complaints (CLAS).

Patients’ Rights

CLAS and JCR emphasize informing patients about their rights, including the right to language assistance (CLAS, JCR) and freedom from discrimination (JCR) in the U.S. JCR and EQS also note the importance of adapting informed consent procedures to patient needs, such as health literacy levels.

Patient and Community Participation at Organizational Level

This domain focuses on involving users and communities in healthcare decision-making at the organizational level, distinct from patient participation in individual care.

Involving Patients and Communities in the Development of Services

All approaches address participation at the organizational level. The primary rationale is that it leads to more responsive care (CLAS, JCR). Another benefit is that patients and communities can contribute to implementing changes (EDS). Approaches implicitly (JCR) or explicitly (CLAS, CRF, COER, EDS, EQS) recognize that target populations often belong to disadvantaged groups less likely to participate in typical participation processes. Therefore, they focus on creating inclusive participation processes.

CLAS, JCR, CRF, and EDS explicitly mention community participation alongside patient participation (COER refers to migrant participation). Community participation brings in the perspectives of those not currently in treatment. Only CLAS and EDS explicitly emphasize building partnerships with community representatives or organizations. They argue that healthcare organizations serve a community, so the community should have influence through collaborative processes. Other approaches see patient and community participation as complementary, without clearly defining the added value of community participation specifically.

Promoting Responsiveness

This domain covers activities that promote responsive healthcare in the wider society. We identified one dimension: sharing information on experiences in improving care for minority patients.

Sharing Information on Experiences

All approaches except CRF mention the importance of sharing experiences to promote responsiveness. This is proposed for various reasons: to increase public support for responsive care (COER), demonstrate organizational commitment (CLAS, JCR), or facilitate mutual learning among organizations (CLAS, EQS). CRF and EQS extend this by suggesting active partnerships with other entities promoting equity in healthcare, including research collaborations.

Unique Issues

Two unique issues emerged in specific approaches. JCR repeatedly mentions identifying and addressing patients’ mobility needs (e.g., canes, guide dogs). EDS uniquely emphasizes “supporting the workforce to remain healthy,” aligning with its focus on workforce equality.

‘Vertical’ Analysis: Comparing Approaches

In the preceding section, we analyzed findings in terms of domains (rows in Table 3). Here, we analyze differences between the approaches themselves (columns) to understand the specific nature of each.

Table 3. The approaches inserted in the analytic framework

DOMAINS & dimensions
Organizational Commitment
Policy and leadership
Measuring and improving performance
Collecting data
Data on the population at large
Data on the patient population
Staff/workforce
Staff competencies
Diversity in workforce
Ensuring access
Entitlement to care
‘Understandable’ information
Geographical accessibility
Other aspects of accessibility
Care provision
Care responsive to needs and wishes
Patient participation in the care process
Overcoming communication barriers in patient-provider contact
‘Understandable’ patient information materials
Trust
Patients’ rights
Patient and community participation at organizational level
Involving patients and communities in the development of services
Promoting Responsiveness
Sharing information on experiences
Unique issues

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CLAS, rooted in the Civil Rights Act of 1964, has a strong legal foundation for its emphasis on linguistic access, mandating federally funded entities to ensure meaningful access for individuals with limited English proficiency. CLAS offers a detailed vision of responsive healthcare, specifying training content and data collection types. While it acknowledges unequal access, CLAS primarily focuses on linguistic barriers.

JCR, originating from the Joint Commission’s hospital standards, follows the clinical care process. Developed as a supplement, it may omit issues already covered in existing Joint Commission standards. JCR’s vision of ‘responsiveness’ is centered around cultural competence, communication, and patient- and family-centered care, with less explicit operationalization of accessibility. Interestingly, the Joint Commission International does recognize accessibility as crucial, emphasizing reducing physical, linguistic, cultural, and other barriers.

CRF, similar to CLAS, primarily addresses cultural and linguistic issues. It provides both quantitative and qualitative indicators for measuring organizational diversity responsiveness.

COER, aimed at governments rather than individual organizations, discusses organizational responsiveness without clearly delineating responsibilities across levels. Reflecting the Council of Europe’s mandate, COER emphasizes the ethical and human rights dimensions of health and social issues.

EDS addresses accessibility and quality of care, but its vision of responsiveness for ‘protected groups’ is less explicit. Its implementation strategy focuses on stakeholder engagement and performance analysis. Responsive care content is broadly defined by goals like ‘better outcomes for all’ and ‘improved patient access and experience.’ A key objective of EDS is to provide a tool for NHS commissioners to comply with the UK’s Public Sector Equality Duty (PSED). This is reflected in EDS’s target groups and its unique focus on staff equality, aligning with PSED’s aim to eliminate discrimination and promote equal opportunities across the public sector.

EQS emphasizes patient vulnerability stemming from various factors, with ‘culture’ being a less prominent factor. It prioritizes individual patient needs and characteristics over group membership, aligning with ‘patient-centered care.’ While targeting ‘migrants and other vulnerable groups,’ EQS standards largely focus on migrant-related issues, possibly due to the Task Force’s origins in the Migrant Friendly Hospital network.

Variations in Approach Orientation

European approaches uniquely address entitlement to healthcare. Non-European approaches commonly emphasize ‘culture,’ although this may be a matter of labeling. For example, CLAS may categorize socioeconomic or legal status differences as ‘cultural.’ European approaches tend to focus on individual characteristics, positioning EQS closer to ‘patient-centered care.’ However, an overly individualistic perspective risks overlooking the social positions of certain groups (e.g., asylum seekers, undocumented migrants). COER and EQS are unique in explicitly referencing ‘migrants’ and considering vulnerabilities related to different migrant statuses (asylum seeker, irregular migrant, labor migrant, etc.).

Discussion

This comparative content analysis of six approaches to organizational diversity responsiveness reveals a significant consensus on the essential actions healthcare organizations should take to address the diverse health needs of their patient populations. The analysis identified seven domains consistently recognized as critical for creating responsive organizations: organizational commitment, data collection and analysis for empirical evidence on inequalities and needs, development of a competent and diverse workforce, ensuring access for all users, ensuring responsiveness in care provision, fostering patient and community participation, and proactively promoting responsiveness. Table 4 summarizes these domains and their coverage across the six approaches.

Table 4. Description of classified domains and dimensions, and coverage of domains/dimensions by the six approaches (the orange cells visualize table 3’s empty cells meaning that this dimension is not covered by that approach)

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These consistently identified elements can serve as a practical guide for implementing diversity-responsive healthcare. They underscore the necessity of involving all stakeholders, including patients and communities, in developing improved services. This consensus paves the way for broader implementation of organizational responsiveness to diversity.

Despite the broad agreement, variations exist in how diversity-responsive healthcare is operationalized, influenced by different scopes, contexts, and diversity definitions. Non-European approaches prioritize care quality and linguistic accessibility to combat health disparities, potentially overlooking ‘entitlement to care.’ This is noteworthy given that lack of health insurance significantly contributes to disparities in the U.S. For instance, the National Health Interview Study 2012 revealed higher uninsured rates for Hispanic, Black, and Asian populations compared to White respondents. While entitlement is typically a governmental rather than provider responsibility, disparity-reduction approaches should acknowledge its importance.

The consensus found in this study aligns with ongoing debates in diversity-responsive care. One debate concerns the relative importance of individual patient characteristics versus cultural or group characteristics. Patient-centered care, while valuable in acknowledging individual patient diversity, risks overlooking group-based inequities linked to social situations. Philimore’s maternity services study in a superdiversity context highlighted immigration status as a major factor in service access issues. Being an asylum seeker or undocumented migrant is a social position with significant health and healthcare access implications, not solely a cultural or individual characteristic. Therefore, diversity-responsive healthcare must consider cultural aspects, social positions, and individual needs comprehensively.

Another relevant debate involves discrimination versus diversity-responsive healthcare. The latter necessitates differentiating care based on patient needs for equitable outcomes, while non-discrimination principles advocate for equal treatment under equal circumstances. Dovidio et al. suggest that while overt racism is less common, explicit egalitarian attitudes may hinder necessary care diversification due to fear of prejudice or stereotyping, potentially leading to suboptimal care. Discrimination was only briefly addressed in most analyzed approaches. Future approaches should elaborate on this dilemma to guide healthcare organizations in navigating this complex issue.

This study has limitations. The sample was limited to approaches from the US, Australia, and Europe, and was not an exhaustive review. Potentially valuable approaches may have been missed. However, the six included approaches showed significant consensus, and data saturation was achieved. Variations in detail level across approaches may limit the analysis’s ability to fully capture underlying visions. For instance, EDS provides a rudimentary conceptualization of responsiveness, which may be further elaborated in other NHS documents.

Conclusion

This study demonstrates a considerable consensus on the key issues healthcare organizations must address to effectively respond to diversity. This consensus offers an opportunity to move forward, resolve terminological discrepancies, and support healthcare organizations in becoming more responsive to the diversity in modern societies.

Abbreviations

CLAS Culturally and Linguistically Appropriate Services (referring to the National Standards for Culturally and Linguistically Appropriate Services in Health Care

JCR Joint Commission Roadmap (referring to Advancing Effective Communication, Cultural Competence, and Patient- and Family Centered Care: A Roadmap for Hospitals

CRF Cultural Responsiveness Framework (referring to Cultural Responsiveness Framework. Guidelines for Victorian health services

COER Council of Europe Recommendations (referring to Recommendation of the committee of ministers to member states on mobility, migration and access to health care

EDS The Equality Delivery System

NHS National Health Service

EQS The Equity Standards (referring to Standards for Equity in Health Care for Migrants and other Vulnerable Groups

WHO-HPH World Health Organization – Health Promoting Hospitals Network

HRM Human Resource Management

PSED Public Sector Equality Duty

Footnotes

Competing interests

MCS, MLE-B and DI are members of the Task Force on Migrant Friendly and Culturally Competent Health Care which is the expert group that developed the Equity Standards (EQS).

DI was a member of the committee that drafted the Council of Europe Recommendations (COER). MCS’s salary as a researcher at the time of this study was paid from funding provided by the Netherlands Organization for Health Research and Development (ZonMw; grant number 510000001). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Authors’ contributions

DI developed the idea for the present comparison. MCS, MLE-B and DI developed the research design. MCS was the primary data analyst. All analyses were checked and discussed with MLE-B and DI. MCS drafted the manuscript. All authors provided input to the manuscript and approved of the final version. Supervision was provided by KS, MLE-B and DI. All authors read and approved the final manuscript.

Contributor Information

Conny Seeleman, Phone: + 31 20 566 4672, Email: [email protected].

Marie-Louise Essink-Bot, Email: [email protected].

Karien Stronks, Email: [email protected].

David Ingleby, Email: [email protected].

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