The First Nations Health Authority (FNHA) completed a self-assessment of the organization's alignment to the British Columbia Cultural Safety and Humility Standard in collaboration with Elder Th'et-simiya and a group of Sisemó:ya Change Champions from across the organization (FNHA and HSO 2022). This article details the organization's processes, including the determination and selection of methods, self-assessment tools used and the lessons learned throughout. Other health and social services organizations are encouraged to use these learnings to guide their own self-assessment processes for continuous learning and development.

Background

The First Nations Health Authority (FNHA) is a First Nations-led organization that supports health and wellness to over 200 diverse First Nations communities in British Columbia (BC). In 2013, in partnership with the First Nations Health Council and First Nations Health Directors Association, the FNHA took over responsibility for the programs and services formerly delivered by Health Canada. The first provincial health authority of its kind in Canada, the FNHA has a unique mandate, working in partnership with First Nations communities, regional health authorities and the provincial and federal governments to accomplish its vision of healthy, self-determining and vibrant First Nations children, families and communities in the province (FNHA 2013).

In 2022, the FNHA and the Health Standards Organization released the BC Cultural Safety and Humility Standard (referred to as the “Standard” from hereon), which outlines ways in which organizations can begin to improve the cultural safety of their governance, services and operations (FNHA and HSO 2022). The Standard details 92 criteria that organizations must achieve to promote cultural safety and humility. Through alignment with these criteria, the policies, practices, structures and functions of organizations can move closer toward First Nations, Métis and Inuit clients, staff and communities feeling safer working with, and receiving services from, health and social service organizations in BC (FNHA and HSO 2022).

The FNHA strives to be a leader in cultural safety and humility and recognizes the importance of gauging its alignment with the Standard (FNHA n.d.). As such, a multi-method self-assessment project was undertaken to better understand the FNHA's alignment with the 92 criteria of the Standard.

To support the work of other organizations seeking to understand their alignment with the Standard, this article presents the process (Figure 1) and tools used by the FNHA in its own self-assessment. The hope is that learnings from the FNHA's experiences can support other organizations in developing their own processes and that the tools can be adapted to fit their unique needs and situation.

Applying the Standard to the FNHA Context

The Standard was written to apply to all healthcare organizations in BC, not specifically for Indigenous-led organizations or organizations with a limited scope of services or clients, such as the FNHA. Therefore, the wording of some criteria did not reflect the nuances of the FNHA's First Nations-led governance structure, primary goals of engagement with First Nations communities and clinical focus on First Nations people.

To focus the Standard within the FNHA context, a project team was assembled and led by the FNHA quality team and supported by the organization's cultural safety and humility team. Members of this project team reflected on the nature of the Standard's eight subsections and their respective sub-clauses, criteria and guidelines. From these reflections, it was determined that FNHA's self-assessment still encompassed all subsections of the Standard but was limited to the FNHA's scope of services. For example, as service delivery within the organization is limited to First Nations clients, considerations regarding Métis and Inuit clients would not apply. However, the organization has a diverse workforce of cultural backgrounds, including First Nations, Métis and Inuit employees. As such, considerations regarding First Nations, Métis and Inuit employees were included in subsections regarding the workforce and human resources.

Developing the Methods and Indicators

With the scope of the project determined, it was clear that there was a need for collaboration across departments within the organization. The project team put out a call for staff who were interested in joining a committee dedicated to informing the self-assessment. Twenty-three staff members volunteered to join. The project team then invited Elder Th'et-simiya from Sq'ewqeyl First Nation to help guide the process. Elder Th'et-simiya shared the Halq'eméylem word for bee, sisemó:ya, with the committee:

Bees have a big job in keeping our environment alive and well. They all work together and think alike to protect their queen and home, making sweet honey for all to enjoy. (W. Ritchie, personal communication, January 17, 2023)

The committee was then named the Sisemó:ya Change Champions, and sisemó:ya became the project symbol.

The Sisemó:ya Change Champions functioned as a safe space to work together and break down silos within the organization. This was accomplished by providing regular communication between teams across FNHA to ensure that there was a coordinated and effective approach to self-assessment and this helped establish relationships to further align the organization with the Standard.

To reduce the workload expected of the Sisemó:ya Change Champions, the project team drafted indicators and methods to self-assess the organization against the Standard's 92 criteria. Project team members worked collaboratively to review each of the criteria descriptions and guidelines to determine the core documents, policies, organizational values or practices that would serve as indicators of alignment with each criterion. Project team members also proposed methods that would be needed to test the indicators, such as interviewing members of the organization's policy team to identify relevant policies and then reviewing the identified policies for alignment with the respective criterion's guidelines. The Sisemó:ya Change Champions then reviewed the proposed indicators and methods as part of four self-selected working groups, which divided the draft indicators and methods into broad organizational categories:

• Collaboration, engagement and process
• Workforce and human resources
• Policy and governance
• Programs and service delivery

The Sisemó:ya Change Champions made recommendations for revisions, removed some indicators and added others. Reflecting the complexity of self-assessment against the Standard, a multi-method approach was approved by the Sisemó:ya Change Champions, including key informant interviews, policy and document reviews, an all-staff survey and analysis of existing organizational data. The final list of 131 data collection points across 121 indicators is presented in Appendix 1 (available online at here).

Data Collection

Data collection took place across all four methods simultaneously and strategically so that data analysis could begin while the project team was awaiting final responses.

Interviews

The Sisemó:ya Change Champions identified individuals or teams within the organization who they felt could best respond to the interview questions, based on their role in leadership or area of expertise. In most cases, multiple people were interviewed per indicator to gain a more wholesome picture of FNHA's alignment. Interview guides were created that included all questions to be asked of any one person or team. The interview guides were then e-mailed to participants who had the option to either respond to the questions via e-mail, participate in an interview or both.

For those who elected to participate in an interview, interviews were conducted by one member of the project team and one member from the Sisemó:ya Change Champions. Other than anonymized notes, interviews were not recorded so as to preserve participant anonymity and encourage candid discussion. Interviewees were sent copies of the interview notes and were provided with the opportunity to redact or provide any additional information.

To ensure that varied perspectives and levels of expertise were reflected in the interview process, interviewees were also asked to recommend anybody else within the organization who could speak to the interview questions.

Policy/document reviews

The Standard often refers to organizational policies or procedures that need to be in place for organizations to demonstrate cultural safety and humility. The Sisemó:ya Change Champions indicated a number of areas where an examination of policy was warranted. Project team members contacted key staff members from across the organization to identify relevant policies. The project team then extracted key statements pertaining to cultural safety, humility and anti-racism and commented on their overall alignment with the guidelines in the Standard.

Other organizational documents, such as collective agreements, position statements and standard operating procedures, were reviewed when indicated or when corporate policies were absent. In these cases, the absence of a policy was noted and the other documents were reviewed in a similar fashion.

All-staff survey

Some indicators required a response from a wider audience. In these cases, survey questions were developed to be distributed through an all-staff survey. As some questions were targeted to only staff in management roles, clinical roles, research roles or who self-identified as Indigenous, participants were asked to respond to between 21 to 39 questions. Participation was incentivized through a randomized draw, with approximately 45% of the FNHA workforce responding to the survey.

Existing FNHA data

Some indicators warranted an investigation of existing FNHA datasets, such as employee training records, employee demographic data, budgets, clinical quality data and community engagement records. In these cases, the project team identified the dataset and went through appropriate data access request processes to obtain and analyze the data. Where direct access to the dataset was unavailable, teams were asked for summary statistics that could be included in the analysis.

Data Analysis

Documents were created that pooled all the data regarding FHNA's alignment with each criterion of the Standard. Members of the project team then used these documents to summarize the data and provide a statement regarding the FNHA's alignment with each criterion. To reduce bias and improve the quality of these summary statements, at least two project team members reviewed the data and summary statements for each criterion.

While many accreditation reviews and associated self-assessments use a dichotomous approach to measuring alignment (met/unmet), the project team feels that this dichotomy does not recognize that cultural humility is a journey of self-reflection and requires us to acknowledge ourselves as learners (FNHA 2016). As such, the project team, Elder Th'et-simiya and the Sisemó:ya Change Champions worked together to create a continuum that acknowledges the good work that has taken place but that ongoing maintenance and commitment are also required. As alignment with each criterion of the Standard exists on a continuum of progress, four stages were used. These stages draw attention to areas where the organization may need further work to align with the Standard and areas where the organization is doing well along its journey (Table 1).

Project team reviewer pairs worked together to place FNHA on the stages of the continuum for its alignment with each criterion and provided recommendations for further alignment where suitable. Wherever there was disagreement between the reviewers, the entire project team reviewed the data and came to a consensus regarding the alignment. The reviewers also had the ability to consult with Elder Th'et-simiya if they had any questions or concerns where they needed support.

Lessons Learned

There are a few key lessons that could be used by organizations that undertake similar self-assessments in the future. These lessons were generated through the project team's reflections of the process and feedback received from participants and others within the organization.

Treat the process as an outcome

One of the strongest outcomes of the FNHA's self-assessment was the gathering of the Sisemó:ya Change Champions. This committee broke down organizational silos and illuminated the organizational strengths that can be used to further alignment with the Standard. Elder Th'et-simiya's guidance and gifting of sisemó:ya to the committee helped unify the organization under a common goal and identity. Other organizations are encouraged to follow a process that emphasizes their own strengths and motivates the organization to improve their alignment.

Provide sufficient resources

A meaningful self-assessment that will produce a clear understanding of the organization's alignment with the Standard and potential areas for further alignment will require human and financial resources. Ensure that the magnitude of the project is understood and that budgeting is adequate. Consider dedicating project managers, evaluation or research specialists and Elders to support and guide the project. Encourage wide participation throughout the organization and budget for the person-time needed to engage in the process.

Allocate the needed time

There are many factors that influence the time needed to engage in a meaningful self-assessment, such as governance and engagement structures, current competing projects or demands, the size of the organization and complexity of service delivery. These factors are different for each organization, and the FNHA's experiences should not be considered an exact estimate of how long this process will take. However, for future self-assessments with a similar scope, an estimated nine months to a year should be considered to encourage maximum participation from the organization and adequate time for data analysis and reporting.

Anticipate participation

Leadership and staff expressed far more interest in participating in this self-assessment than the project team had anticipated. Unfortunately, the project team had to limit the scope of responses in order to ensure timely completion. Participants wanted to share more about their experiences and ideas for improvement. Make the time and additional efforts to encourage this participation. Market the self-assessment to the entire organization and open other communication avenues for employees to share their thoughts and perspectives to make the process more inclusive. Ultimately, a self-assessment should be truly reflective of the organization and this is best accomplished by listening to the organization as a whole.

Celebrate in ceremony

It was important to celebrate the important work of the Sisemó:ya Change Champions in a way that was grounded in culture and connection. A blanketing ceremony was hosted at Kwantlen First Nation following the conclusion of the Sisemó:ya Change Champions' role with the project. Participants expressed that the ceremony was a highlight of their time with the organization, allowed them to build stronger connections with peers across departments, and further inspired them to commit to the advancement of cultural safety and humility. With the support of Elders and local Knowledge Keepers, organizations should thank those who contributed to the work in a meaningful and cultural way.

Discussion

The FNHA's place in this work is unique as it is a First Nations-led organization with a mandate to serve First Nations communities and employ many Indigenous staff. The organization's work is focused on serving BC First Nations and First Nations living in BC and cultural safety and humility are at the forefront of this work. Despite these factors, there will always be room for improvement. This self-assessment is an important step in the improvement process. Continuous cycles of self-assessment will demonstrate progress and indicate further opportunities for growth.

Other health and social service organizations in BC are encouraged to use the learnings from the FNHA's self-assessment to help guide their own self-assessment journeys. Cultural safety and humility are not simply checking a box in an accreditation survey. Ultimately, it will be the First Nations, Métis and Inuit clients who will let the healthcare system know that it is culturally safe. However, a careful and thoughtful self-assessment, which acknowledges both progress and room for improvement, is an important first step.

Comments

Be the first to comment on this!