4.1 Legal, Regulatory, and Accreditation Issues

The Oregon Health Authority (OHA) has established regulations against discrimination in any of its programs in relation to protected classes as defined by State of Oregon law and Federal law. Protected classes include but are not limited to:

• age (18 or older)
• national origin
• color
• pregnancy
• disability
• race
• gender identity
• religion
• limited English proficiency
• sex
• marital status
• sexual orientation (OHA, Nd)

Non-discrimination policies and procedures are posted within the Oregon Administrative Rules, which outlines, along with other policies, that the Oregon Health Authority shall not, either directly or through another entity, discriminate against any individual, or harass, exclude from participation, or deny the benefit of programs, services, or activities because the individual belongs to a protected class (Oregon Secretary of State, 2022).

The full text of Oregon’s non-discrimination policy is available here.

4.1.1 Patient Rights and Responsibilities

Commonly established patient rights derive from the field of ethics. Modern bills of patient rights establish that people can expect certain treatment regardless of their socioeconomic status, religious affiliation, gender, or ethnicity (Olejarczyk and Young, 2022).

Oregon Administrative Rules (OAR 333-700-0115) establish patient rights and responsibilities for healthcare facilities. These rules require that healthcare facilities establish and maintain policies and procedures related to patient care. Among other rules, patients must be informed of their rights and responsibilities, be allowed to participate in the planning of their medical care, be treated with consideration and respect, and be informed of the facility’s grievance process (Oregon Laws, 2021).

The full list of patient rights and responsibilities for Oregon healthcare facilities can be accessed here.

4.1.2 Civil Rights Laws and Regulations

Healthcare organizations and their employees are required by state and Federal law to implement nondiscrimination policies including Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, Oregon Revised Statute Chapter 659A, and Section 1557 of the Affordable Care Act.

Civil Rights Act of 1964

More than 50 years ago, one of the most important civil rights laws in our nation’s history was signed into law by President Lyndon Johnson. Title VI of the landmark Civil Rights Act of 1964, stated:

“No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”

Title VI of the act prevents discrimination by programs and activities that receive federal funds, including hospitals and other healthcare facilities.

The Americans with Disabilities Act of 1990

This Act provides equal opportunities for people with disabilities as well as a comprehensive national mandate for the elimination of discrimination against individuals with disabilities. It provides clear, strong, consistent, enforceable standards addressing discrimination against individuals with disabilities and ensures that the Federal government plays a central role in enforcing the standards established on behalf of individuals with disabilities. The Act invokes the sweep of congressional authority, including the power to enforce the 14th amendment and to regulate commerce, in order to address the major areas of discrimination faced day-to-day by people with disabilities (ADA.gov, 2023).

Rehabilitation Act of 1973

Section 504 of the Rehabilitation Act of 1973 states: “no otherwise qualified individual with a disability in the United States, as defined in section 705 (20) of this title, shall, solely by reason of his or her disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance or under any program or activity conducted by any Executive agency or by the United States Postal Service (USDOL, Nd).

Oregon Revised Statute Chapter 659A

This statute covers unlawful discrimination in labor and employment. It prohibits discrimination based on:

• race
• color
• religion
• sex
• sexual orientation
• national origin
• marital status
• age

The full statute is available here.

Section 1557 of the Affordable Care Act (ACA)

This act prohibits discrimination based on race, color, national origin, sex, age, or disability in certain health programs and activities. The ACA states that an individual shall not, on the grounds prohibited under Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, or Section 504 of the Rehabilitation Act of 1973, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under, any health program or activity, any part of which is receiving Federal financial assistance, or under any program or activity that is administered by an Executive Agency or any entity established under Title I of the Act or its amendments. Enforcement mechanisms available under Title VI, Title IX, Section 504, or the Age Act shall apply for purposes of addressing violations (HHS, 2016).

The entire section 1557 of the ACA is available here.

OR Senate Bill 567

In 2021, Oregon passed Senate Bill 567, establishing the right to be free from unlawful discrimination and bias in the healthcare system. SB 567 clarifies that it is unlawful for an individual licensed or certified by a health professional regulatory board, hospital, a long-term care facility, an ambulatory surgical center, a freestanding birthing center, an outpatient renal dialysis facility, or an extended stay center to discriminate on the basis of a protected class by:

• denying medical treatment to the patient that is likely to benefit the person based on an individualized assessment of the patient using objective medical evidence; or
• limiting or restricting in any manner the allocation of medical resources to the patient (DRO, 2023).

4.1.3 Joint Commission Standards

Effective January 1, 2023, new and revised requirements to reduce healthcare disparities apply to organizations in the Joint Commission’s ambulatory healthcare, behavioral healthcare and human services, critical access hospital, and hospital accreditation programs (JC, 2022).

Based on the idea that healthcare disparities are “quality of care” issues, the Joint Commission requires healthcare organization to examine and understand the root causes of health disparities and address them with targeted interventions. The Joint Commission has established regulations to improve patient-provider communications as well.

4.1.4 Higher Education

In the U.S., the inclusion of diversity in policies and plans in higher education dates to the Civil Rights Movement of the 1960s. During that era, important regulations—including the Civil Rights Act in 1964 and executive orders about affirmative action introduced diversity policies into government regulations. Previous regulations also had some impact, including the 14th* and 15th** amendments to the Constitution in 1868 and 1870, and the 2nd Morril Act that promoted the creation of the Historically Black Colleges and Universities (HBCUs in 1890 (Buenestado-Fernández et al., 2019).

*14th amendment: passed after the U.S. Civil War, stated that all persons born or naturalized in the U.S. are U.S. citizens, no state can deprive any person of life, liberty, or property without due process or law, nor deny any person of equal protection of the laws.

**15th amendment: The right of citizens of the United States to vote shall not be denied or abridged by the United States or by any State on account of race, color, or previous condition of servitude.

Schools that educate healthcare providers employ a variety of teaching methods that allow students to explore their attitudes, increase their knowledge, and develop relevant cultural competency skills. Most encourage active student participation through case studies and group-based discussions. However, there are considerable variations in teaching methods across schools and across teaching areas (Liu, Miles, and Li, 2022).

Cultural competence training has mostly focused on developing knowledge, attitudes, awareness, and sensitivity for those working in healthcare. However, the literature reiterates the need to reach further and focus on teaching the skills needed to translate knowledge and awareness into tangible practitioner behaviors which can be consistently applied and assessed in healthcare encounters and settings (Jongen et al., 2018).

4.1.5 Accreditation Standards

Agencies that provide accreditation to educational institutions have, until recently, had few standards related to diversity, equity, and inclusion. This is beginning to change as the impact of the COVID-19 pandemic uncovered horrific disparities in the availability of health services, especially in under-resourced and minority communities.

In the field of nursing, as in other professions, accreditation is a non-governmental, voluntary, self-regulatory, peer-review process that recognizes programs that meet or exceed standards that ensure educational quality. Nursing programs in the U.S. may choose to seek accreditation from 1 of 3 nursing accreditation bodies. Of these three, only the National League for Nursing Commission for Nursing Education Accreditation (CNEA) has criteria that relates to ethnic minority diversity and inclusion with respect to both students and faculty (Iheduru-Anderson and Wahi, 2021).

In an effort to diversify the healthcare workforce, the Liaison Committee on Medical Education adopted formal accreditation guidelines in 2009 that require medical schools to develop programs or partnerships designed to “make admission to medical education more accessible to potential applicants of diverse backgrounds” (Lett et al., 2019).

In 2021, the Council for Higher Education Accreditation added requirements to its accreditation standards saying, “every recognized accrediting organization must demonstrate that it manifests a commitment to diversity, equity, and inclusion.”

Although the COVID-19 pandemic and the Black Lives Matter movement have exposed long-standing inequalities in society and healthcare, cultural competence training remains inconsistent across medical schools, and little is known about how students develop their cultural competence through campus-based classroom teaching (Liu, Miles, and Li, 2022).

4.1.6 Professional Standards and Cultural Competence

Human resource departments are often tasked with overseeing cultural competence education and training within health organizations. Healthcare systems usually employ one, or a combination, of several popular cross-cultural training models. This can include training in cultural awareness, cultural safety, cultural humility, cultural intelligence, and cultural competence. Other off shoots include anti-racism and diversity training (Shepherd et al., 2019).

The general focus of cultural competence workforce training has been on educating and training the healthcare workforce with the knowledge, attitudes, and skills needed to effectively respond to sociocultural issues arising in clinical encounters. Cultural competence training usually includes:

• understanding the central role of culture in all lives and how it shapes behavior; and
• learning to respect and accept cultural differences; and
• learning to utilize culturally adapted and culturally specific practices; and
• developing awareness of personal cultural influences and prejudices or biases (Jongen et al., 2018).

4.2 Oregon Resources

4.1.1 OR Equity Advancement Plan

The Oregon Health Authority (OHA) is a state government agency with an overarching strategic goal: eliminate health inequities in Oregon by 2030. The equity advancement plan primarily focuses on communities experiencing health inequities and the healthcare system that has failed to serve them. Guided by its Affirmative Action Plan, the OHA uses a variety of proactive efforts to advance workforce equity and inclusion (OHA, 2023).

The OHA has established the Office of Equity, Health Disparities, and Cultural Competence to addresses the needs of diverse populations. This office is responsible for developing, implementing, and evaluating health equity initiatives that reduce health disparities among vulnerable populations.

4.1.2 Developing Equity Leadership through Training & Action

Developing Equity Leadership through Training & Action (DELTA) is a leadership program in Oregon that includes training, capacity building, and networking for health, community, and policy leaders. The purpose of this program is to promote equity and diversity within Oregon’s public health and health systems (OEI, 2022).

DELTA includes 40 hours of classroom training, hours of individualized technical/coaching assistance, and facilitates opportunities for cross-sector partnership. Each participant submits a project proposal that drives and institutionalizes best practices in their organizations that promote health equity and inclusion (OEI, 2022).

4.1.3 Oregon Health Care Interpreter Program (HCI)

Health Care Interpreters (HCIs) are bilingual individuals who help people in their communities by providing high quality health care interpretation at in person medical appointments or over the phone. The purpose of the Health Care Interpreter (HCI) programs is to help HCIs in Oregon become trained and qualified or certified to meet current requirements, diversify the healthcare workforce in Oregon, provide high-quality healthcare interpretation to Oregon's growing diverse populations, and promote health equity (OHA, 2022).

4.1.4 Additional Oregon Programs

Additional initiatives and programs aimed at improving cultural competence in Oregon’s healthcare systems include:

• Oregon Equity and Inclusion Division—carries out more than 16 distinct functions for the state, providing expertise and technical assistance on equity, inclusion, anti-racism, anti-oppression, universal accessibility, and social justice topics.
• Oregon Health Equity Alliance—a statewide coalition of organizations, agencies, and individuals working to advance health equity and reduce health disparities.
• Health Equity Network—a coalition of community health clinics—provides technical assistance to the OHA and other stakeholders on health equity issues.