Procedure - Cultural Competency and Non-Discrimination

​Responsible Party

Action Required​​


1.  BHSD will comply with the provisions of BHSD’s Cultural Competency Plan, and will annually update and submit any changes to DHCS for review and approval.

2.  BHSD will establish a functional/organizational structure and staffing to appropriately meet its service population’s cultural and linguistic needs and health equity. 

  • BHSD supports and sustains an independent Cultural Competence Advisory Committee to oversee cultural competence activities.

  • BHSD ensures the allocation of sufficient funds to support cultural competence and health equity.

  • BHSD provides staff support to the Cultural Competence Advisory Committee.

  • BHSD updates and refines its Cultural Competency Plan to assist the population it is meant to serve and in accordance to the State of California Cultural Competency Plan Requirements, national standards for CLAS, and the County Behavioral Health Directors Association of California Framework for Advancing Cultural, Linguistic, Racial and Ethnic Behavioral Equity and the strictest standards set by the County.

  • BHSD creates, revises, and enforces cultural competency relevant policies and procedures. BHSD enforces existing policies and procedures, which are:​

v  P&P BHSD # 7300 Non- Discrimination

v  P&P BHSD # 11400 Beneficiary Rights

v  P&P BHSD # 11300 Providing Language Services

v  P&P BHSD # 12000 Beneficiary Problem Resolution

v  P&P BHSD # 350 Bilingual Certification

3.  BHSD will sustain transparent fiscal accountability, clinical and support services contracts management, human resources recruitment and management, and preserve access, delivery, and high quality of culturally and linguistically appropriate services to the population it serves.

  • BHSD protects the development of the county and contracted services to meet its population’s cultural and linguistic service needs and health equity.

  • BHSD engages in continuous quality improvement to include data collection, needs assessments, research, monitoring and evaluation, and reporting of activities to address services access (outreach and engagement), quality, outcomes (wellness, wellbeing, and recovery), and health equity.

           4.   BHSD ensures mandated trainings in cultural competency.​

  • BHSD makes sure that all staff of county and contracted agencies and Behavioral Health Board appointees of the County Board of Supervisors (BOS) attend the training in "Foundations​ in Cultural Competency" within the first six months of an official service appointment.

  • BHSD makes sure that all staff takes the brief Cultural Competency refresher course (web-based) once every year.

  • BHSD makes sure that all staff of county and contracted agencies receive annual training on Client Culture that includes a client’s personal experiences inclusive of racial, ethnic, cultural, and linguistic communities. Topics may include culture-specific expressions of distress, explanatory models and treatment pathways, the relationship between client and mental health provider from a cultural perspective, trauma, economic impact, housing, diagnosis/labeling, medication, hospitalization, societal/familial/personal, discrimination/stigma, effects of cultural and linguistically incompetent services, involuntary treatment, wellness, recovery, and; culture of being a mental health client, including the experience of having a mental illness and of the mental health system.

  • BHSD makes sure that all direct/clinical service staff of the county and its contracted agencies attend advanced level trainings in cultural competency within the first year of employment with BHSD or its contracted agencies (Examples of Training Areas: Cultural Sensitivity in Assessment, Diagnosis, and Engagement; Population Specific Sensitivity Training; Interpretation and Translation; and, Culture and Evidence-Based Practice Models).

  • BHSD ensures continuous learning through provision to or attendance of staff in training meetings, workshops, and conferences that are relevant to advancing the field of cultural competency and health equity.

  • BHSD allocates funds (e.g., stipends and scholarships) for students in clinical and health-related graduate and undergraduate programs in working towards health equity and protect cultural competence skills and knowledge capital.

  • BHSD oversees training and use of appropriate system-wide assessment and diagnostic, outcomes, and service satisfaction tools to ensure cultural competence.

BHSD Director​

  • ​ Maintains collaboration with the Cultural Competence Advisory Committee.

  • Ensures there is a staff liaison for the BHSD and Cultural Competence Advisory Committee.

  • Designs and leads an efficient and effective organization staffed for stable and long-term relevance and development.

  • Ensures annual budget plans and expenditures reports are available for review and comments by the Cultural Competence Advisory Committee.

  • Ensures annual cultural competence plans and progress reports are available for review and comments by Cultural Competence Advisory and Quality Improvement Committees.

  • Ensures and approves sufficient funding for cultural competence and health equity.

  • Reviews and approves clinical and support services and staffing plans submitted by BHSD Executive Directors and Division Directors.

  • Reports to County Valley Medical Center Executive Director and Deputy Executive Director.

Cultural Competence Advisory Committee

  • Provides oversight function.

  • Establishes and updates by-laws for Cultural Competence Advisory Committee (Include: membership qualifications, roles and responsibilities and terms of appointment).

  • Reports to the County Board of Supervisors.

  • Advises Behavioral Health Services Department Director.

  • Reviews and comments on cultural competence plans and progress reports.

Ethnic Services Manager​​

  • Serves as liaison for the BHSD and the Cultural Competency Advisory Committee.

  • Reports to the BHSD Director

Executive Management and Division Directors

  • Submits respective services and staffing plans for review and comments by the Cultural Competence Advisory Committee and BHSD Director.

  • Implements approved clinical and support services plans.

  • Oversees respective county and contracted services for cultural competence and health equity.

Quality Improvement: Decision Support and Research

  • Collects data, performs needs assessments, research and evaluation.

  • Ensures availability of data reports to inform the Behavioral Health Services Director, Cultural Competence Advisory and Quality Improvement Committees, and Clinical Services and Support Services Directors, and the general public.

Administration: Compliance and Contracts Management; Quality Assurance and Management​

  • ​​Enforces all U.S., State of California, Santa Clara County and BHSD cultural competency relevant rules, regulations, policies, and procedures that have been enacted.

  • Report to BHSD Director.

​Services Contract Monitors

  • M​onitors respective county and contracted services performance agreement.

  • Reports to respective Directors.

Quality Improvement: Training Team​

  • Develops, provides, and monitors system-wide cultural competency trainings.

  • Ensures reports are available to BHSD Director and Cultural Competence Advisory Committee for comments and review.

  • Develops training plans and agreements with contracted agencies to improve training attendance.

Administration and Quality Improvement​

  • Creates/develops, reviews, and updates policies and procedures to support cultural competence and health equity.

  • Reviews performance metrics for cultural competency and health equity.

  • Facilitates review and recommendation of assessment and outcomes tools and evidence-based culturally competent practice models.

  • Facilitates use of assessment tools and outcomes data collection.

  • Reports to BHSD Director.

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