There are several things to consider when undertaking an organizational assessment, beginning with its basic structure and steps. After the Implementation Team convenes and agrees on the overall design, it must determine the type of information it will obtain, which groups of stakeholders will take part, the methods for gathering information, and how the resulting information will improve access to and quality of services for SGM patients.
Structure and Steps of an Organizational Assessment
The National Center for Cultural Competence (NCCC) identifies four steps to conducting organizational assessments.1 Per Figure 6.1, these steps have been adapted by Goode and Fisher2 for SGM communities:
- Assemble a workgroup (e.g., Implementation Team) to guide the organizational assessment. Bring together colleagues in an Implementation Team (see Chapter 2) to lead in planning, implementing, overseeing the assessment process, and sharing the results where appropriate. The group should be inclusive and have representation from all levels of the clinic.
- Create a shared vision and shared ownership. The team should consult with others in the clinic about their perception of current practices and vision for serving SGM people and the overall focus of the assessment. The team can do this through individual, group, or virtual meetings. It is important to strive for broad participation and a diversity of perspectives about what it will take to serve SGM patients responsibly and effectively.
- Collect, analyze, and share data. The organizational assessment process can draw from many data sources, such as quantitative surveys and questionnaires, qualitative interviews and focus groups, and clinic and/or regional datasets. The team must decide which assessment strategies are appropriate to obtain the desired information and then collect and analyze these data. The team can also tailor reports of findings for dissemination to different audiences and constituents.
- Develop and implement an Action Plan. The team should create an Action Plan using the results of the organizational assessment. The plan will define priorities and steps for reaching the targeted goals for the clinic. The plan should include the strategies, activities, partners, resources, timetables, and responsible parties necessary to improve services and supports for SGM patients. It should also have links to SMART objectives that include milestones or benchmarks to track implementation and see how well changes are being implemented and sustained.
Figure 6.1. Organizational Assessment Process
This figure depicts the structure and steps of an organizational assessment process adapted from the NCCC.1
Taking Part in an Organizational Assessment
Organizational assessments are most effective when they engage personnel at multiple levels across a clinic. Broad participation and diverse perspectives will result in the most thorough understanding of a clinic’s capacity and readiness for improving SGM health and health care, including its strengths and weaknesses. All clinic stakeholders may be involved in an organizational assessment, including administrative staff, health professionals, clinic managers, and executive leadership. Importantly, organizational assessments should also include patient perspectives regarding their experiences of care in the clinic and changes they would like to see implemented.
Type of Information Gathered in an Organizational Assessment
Organizational assessments should systematically examine a clinic’s vision, mission, governance structure, strategic plans, policies, procedures, administrative forms, research portfolio, and service delivery mechanisms. They should also consider websites, publications/print documents, and multimedia resources to ensure that they are inclusive of SGM considerations. Where such support is implicit, the team may consider changes to make it more explicit when it plans for organizational change. The team should also be prepared to draw on such documents to bolster its change efforts among coworkers.
Attitudes, biases, and implicit assumptions about SGM people that staff members bring to the workplace can consciously or unconsciously affect the quality of care for SGM patients. Therefore, we strongly suggest that organizational assessments encourage all employees to examine their personal beliefs and identify gaps in their knowledge, understanding, and acceptance.
Experts have identified six elements of successful SGM organizational change in healthcare settings.3 Each element is described in Table 6.1 below. We encourage the Implementation Team to gather information regarding each element to determine what to focus on when developing Action Plans.
| ||||
| Elements and Processes for Successful SGM Organizational Change3 | ||||
| Element for Success | Description | Example of Element in Practice | ||
| Change champion | Visionary leaders skilled at initiating, facilitating, and implementing change |
| ||
| Organizational priority | SGM diversity and inclusion are prioritized among institutional goals and mission |
| ||
| Depth of Mission | Goals and mission embedded across the organization |
| ||
| Commitment to continuous learning | Capacity for performance monitoring and evidence-based direction to achieve learning goals continuously |
| ||
| Commitment to diversity and inclusion | Diversity and inclusion are “hard-wired” in the organization’s policies, performance, metrics, and training |
| ||
| Organizational resources | Available and devoted human, financial, technological, and other resources for achieving the organization’s mission and goals |
| ||
Methods Used in an Organizational Assessment
There is no one method for doing organizational assessments. Specific to this toolkit are survey, questionnaire, and qualitative tools aimed at organizational readiness for change (meaning the extent to which employees are psychologically and behaviorally prepared to implement new initiatives),4 general linguistic and cultural competence, capacity to support SGM health, and individual attitudes, comfort, behaviors, and language. Table 6.2 points to possible data collection tools that might be relevant to an organizational assessment related to SGM health care. Many of these tools are also useful for looking at how well the clinic serves other patient populations, including racial and ethnic minorities.
| Table 6.2 |
| Data Collection Tools for Conducting Organizational Assessments | |||
| Domain | Tool | Details | Access |
| Organizational Readiness for Change | Organizational Readiness to Change Assessment (ORCA) | 77-item assessment comprising three major scales: 1) strength and extent of evidence for the change; 2) quality of the organizational context for the change; and 3) capacity for internal facilitation of the change. | ORCA validation study and measure can be accessed freely from the Implementation Science journal: click here |
| Organizational Readiness for Change | Organizational Readiness for Implementing Change (ORIC) | 12-item assessment comprising two major factors: 1) commitment to change (e.g., “We are committed to implementing this change;” and 2) change efficacy (e.g., “We can coordinate tasks so that implementation goes smoothly”). | ORIC validation study and measure can be accessed freely from the Implementation Science journal: click here |
| Organizational Readiness for Change | Texas Christian University (TCU) Organizational Readiness for Change (ORC) | 129-item provider survey, and 115-item director survey on 1) motivational factors (program and training needs, pressures for change); 2) program resources (facilities, staffing, training, equipment, and Internet); 3) staff attributes (growth, efficacy, influence, adaptability, and clinical orientation); and 4) climate (mission, cohesion, autonomy, communication, stress, and openness to change). | TCU ORC measures can be accessed freely at the following website: click here |
| General Cultural and Linguistic Competence | National Center for Cultural Competence’s (NCCC) Promoting Cultural and Linguistic Competence Self-Assessment Checklist for Personnel Providing Primary Health Care Services | 37-item checklist assessing: 1) physical environment, materials, and resources; 2) communication styles; and 3) values and attitudes. | NCCC Self-Assessment Checklist for Personnel Providing Primary Health Care Services can be accessed freely at the following website: click here |
| General Cultural and Linguistic Competence | Downstate Medical Center Cultural Competence Self-Assessment | 17-item semi-structured interview to assess an organization’s overall cultural competence and identify steps for action. as well as 122-item assessment tool divided into the following three sections: 1) ethnic/cultural characteristics of the staff; 2) healthcare organizational approaches to accommodating diversity needs and attributes; and 3) healthcare organizational links to the communities served as well as patient and staff initiatives. | Cultural Competence Self-Assessment questionnaire and interview guide can be accessed freely at the following website: click here |
| General Cultural and Linguistic Competence | Substance Abuse and Mental Health Services Administration’s (SAMHSA) Improving Cultural Competence Treatment Improvement Protocol | Comprehensive document with introduction to cultural competence, core competencies for clinic staff, evaluation and planning resources, and a variety of instruments and tools for assessing and developing cultural competence. | SAMHSA’s Improving Cultural Competence document can be accessed freely from the SAMHSA website: click here |
Organizational assessments can involve qualitative interviews and focus groups that feature open-ended questions. In contrast to the closed-ended questions with limited response options used in surveys and questionnaires, open-ended questions do not restrict the length or content of responses, allowing people to answer in their own words and share information about their perceptions and experiences. Importantly, interviews and focus groups are a great way to hear directly from both employees and patients about the clinic’s strengths and areas for improvement. When asking open-ended questions about sensitive topics to improve services, it is unnecessary to ask participants to reveal personal information but instead focus on their improvement suggestions and how best to act on their advice. Table 6.3 provides sample questions for SGM organizational change adapted from the SAMHSA Cultural Competence Self-Assessment.1
| |
| Sample Open-Ended Questions Relevant to SGM Organizational Change | |
| 1. What are some of the challenges involved in delivering primary care to gay, lesbian, and bisexual patients at this clinic? What about the challenges in providing care to transgender patients? | |
| 2. How does this clinic support you in caring for lesbian, gay, and bisexual patients? Transgender and gender-diverse patients? | |
| 3. How do you define culturally competent care for sexual and gender minority patients? How prepared are you to deliver such care? | |
| 4. How important is it to make changes at the clinic to increase the cultural competence of primary care services for transgender and gender-diverse patients? For lesbian, gay, and bisexual patients? | |
| 5. What support does this clinic need to enhance services for transgender and gender-diverse patients? Lesbian, gay, and bisexual patients? |
Finally, organizational assessments may involve collecting community, regional, state, territorial, tribal, and organizational demographic data (Appendix E). The specific data sources to be tapped should depend on the focus of the organizational assessment. However, the inclusion of a range of data sources with different emphases or perspectives is likely to lead to a more robust analysis and a more comprehensive understanding of the clinic’s strengths and weaknesses in serving SGM people.