cultural competence and health care
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Cultural Competence and Health CareTRANSCRIPT
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Cultural Competence in Health Care:Overcoming Language Barriers as a Strategy to Improve the Safety and Quality of Health Care
Cheri Wilson, MA, MHS candidate, CPHQQuality Improvement Team LeaderThe Johns Hopkins Hospital
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Objectives
This presentation will provide an overview of:• The effects of language barriers on patient safety
and healthcare quality• The needs of limited English proficiency (LEP)
patients• The importance of using non-English materials
and providing access to language services• Experiences, lessons learned, and success
stories from Johns Hopkins Hospital and other organizations
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Scope of the Problem: U.S. Demographics
• As the United States becomes increasingly diverse, healthcare organizations struggle to provide culturally and linguistically appropriate services (CLAS) for LEP patients
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Scope of the Problem: U.S. Demographics
• Almost 35 million U.S. residents are foreign born.
• Almost 55 million people (19.7% of the U.S. population) speak a language other than English at home.
• More than 24 million people (8.7% of the U.S. population) speak English less than "very well" and are considered LEP.
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Federal Mandates and Regulations
• Title VI of the Civil Rights Act of 1964 considers the denial or delay of medical care due to language barriers to be discrimination.
• Similarly, any medical facility receiving Medicaid or Medicare must provide language assistance to LEP patients.
• In addition, The Joint Commission, which accredits healthcare organizations, requires that interpretation and translation services be provided as necessary.
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Federal Mandates and Regulations
• However, neither of these mandates includes funding.• The burden of the cost of language services remains
the responsibility of the provider. – An American Medical Association (AMA) survey
found that the cost of interpreter services ranged from $30 to $400 per hour, while the average Medicaid office visit reimbursement was only $30 to $50.
– Private payers generally do not reimburse for interpreter services.
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Federal Mandates and Legislation
• Two major impediments to providing language services are:
– Lack of availability of qualified, medical interpreters, and
– Inadequate funding
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Patient Safety and Healthcare Quality
• Research studies have documented that the safety and quality of healthcare of LEP patients can be diminished due to language barriers.
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Patient Safety and Healthcare Quality
• One study found that in 46% of emergency department cases, no interpreter was used for LEP patients.
• In addition, only 23% of teaching hospitals train physicians how to work with an interpreter.
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Patient Safety and Healthcare Quality
• A study analyzed 1,083 adverse incident reports from six Joint Commission-accredited hospitals for English speaking vs. LEP patients for 7 months in 2005. – This study found that a greater percentage of LEP
patients experienced physical harm versus English-speaking patients, 49.1% and 29.5% respectively.
– The LEP patients also experienced higher levels of physical harm ranging from moderate temporary harm to death, 46.8% and 24.4% respectively.
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Patient Safety and Healthcare Quality
• In an effort to provide language services, healthcare providers have sometimes resorted to drastic measures.
• At one hospital, the emergency room used the Yellow Pages to find a restaurant that spoke a particular language and would ask one of the restaurant employees to interpret over the phone.
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Patient Safety and Healthcare Quality
• Other hospitals have used:– untrained support staff, – strangers found in the waiting room or
on the street, – taxi cab drivers, etc.
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Patient Safety and Healthcare Quality
• In many instances, a family member serves as an interpreter, which raises privacy and other concerns. – For example, California State Senator Leland
Yee remembers translating for his mother at the doctor's office when he was only six years old.
• Several states have introduced legislation forbidding children under sixteen from serving as interpreters.
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Patient Safety and Healthcare Quality
• Untrained interpreters are more likely to commit errors in interpretation that can lead to adverse clinical consequences.
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Patient Safety and Healthcare Quality
• Concerns about untrained interpreters include:– Lack of knowledge of medical terminology
and confidentiality, – Their priorities may conflict with those of
the patients, and– Their presence may inhibit discussions of
sensitive issues, such as:• domestic violence, substance, abuse, psychiatric
illness, and sexually transmitted diseases.
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Patient Safety and Healthcare Quality
• Occasionally, a bilingual healthcare provider may be present.
• However, this is not without its problems as well. – For example, in one case, a mother lost
custody of her two-year old child who fell off her tricycle because the doctor misinterpreted two Spanish words (Se pegó) as "I hit her" instead of "She hit herself."
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Patient Safety and Healthcare Quality
• Care can be compromised or delayed in the absence of any language service (trained or untrained).
• In other instances, the consequences can be catastrophic.
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Patient Safety and Healthcare Quality
• A health care team misunderstood an eighteen year old man who said that he was intoxicado. – The team misunderstood the term to mean
"intoxicated" rather than “nauseated.” – As a result, the patient was treated for a drug
overdose for thirty-six hours before the doctors realized that he had a brain aneurysm.
– He ended up being a quadriplegic and his family was awarded $71 million in a malpractice settlement.
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Discussion
• What issues arose during this scenario?
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Discussion
• How was this scenario improved with the assistance of a trained, staff interpreter?
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Best Practices: The Johns Hopkins Hospital
• Per the JHH Interdisciplinary Clinical Practice Manual (ICPM) policy, “PAS002: Interpreting Services,” foreign and sign language interpreters are available to patients.– For foreign languages, call Johns Hopkins
International Services at 4-INTL (4-4685)• On-site interpreters are available for the most commonly
spoken foreign languages during business hours
• After business hours, a 24/7 language line is available.
– For sign language, call Patient Relations at 410-955-2273.
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Best Practices: The Johns Hopkins Hospital
• According to the policy, interpreters must be provided to patients and/or family members under the following circumstances:– Obtaining the patient’s medical history;– Explaining the plan of care and periodic updates
on the plan of care– Discharge planning discussions– Explaining procedures
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Best Practices: The Johns Hopkins Hospital
• According to the policy, interpreters must be provided to patients and/or family members under the following circumstances:– Obtaining consent;– Providing patient education, including discharge
instructions; and– Having discussions about advance directives.
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Best Practices: The Johns Hopkins Hospital
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Best Practices: The Johns Hopkins Hospital
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Best Practices: The Johns Hopkins Hospital
• Johns Hopkins International has translated certain patient education materials into various foreign languages.
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Best Practices: The Johns Hopkins Hospital
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Best Practices: The Johns Hopkins Hospital
• In addition, Patient Education materials are available in English and Spanish in Micromedex CareNotes™.
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Best Practices: The Johns Hopkins Hospital
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Resources
• National Standards on Culturally and Linguistically Appropriate Services (CLAS)http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15
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Resources
• Limited English Proficiency: A Federal Interagency Websitehttp://www.lep.gov/resources/resources.html
• Hablamos Juntos: Language Policy and Practice in Health Carehttp://www.hablamosjuntos.org/– Also see: Universal Symbols in Health Care
http://www.hablamosjuntos.org/signage/symbols/default.symbols.asp
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Resources
• Speaking Together: National Language Services Networkhttp://www.speakingtogether.org/
• National Health Law Program: Language Access in Health Care Statement of Principleshttp://www.healthlaw.org/library/item.71365
• HRET Disparities Tool Kit: A tool kit for collecting race, ethnicity, and primary language from patientshttp://www.hretdisparities.org/
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Resources
• Diversity Rxhttp://www.diversityrx.org/– Quality Healthcare for Culturally Diverse Populations
Conferencehttp://www.diversityrxconference.org/
• A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizationshttp://www.omhrc.gov/Assets/pdf/Checked/HC-LSIG.pdf
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Resources
• Joint Commission: Hospitals, Language, and Culture: A Snapshot of the Nationhttp://www.jointcommission.org/NR/rdonlyres/E64E5E89-5734-4D1D-BB4D-C4ACD4BF8BD3/0/hlc_paper.pdf
• Joint Commission: One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populationshttp://www.jointcommission.org/PatientSafety/HLC/one_size_meeting_need_of_diverse_populations.htm
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Resources
• Oral, Linguistic, and Culturally Competent Services: Guides for Managed Care Planshttp://www.ahrq.gov/about/cods/cultcomp.htm
• Providing Oral Linguistic Services: A Guide for Managed Care Planshttp://www.ahrq.gov/about/cods/oralling.htm
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Resources
• White Paper: “For the Health Care CEO: Thinking about Language Access in Health Care” – by Edward L. Martinez, MShttp://www.pgsi.com/Products/Resources/WhitePapers/WhitePaper1.aspx
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Resources
• Open invitation to comment on the National Quality Forum’s proposed “Framework and Preferred Practices for Measuring and Reporting Cultural Competency”http://www.qualityforum.org/projects/ongoing/cultural-comp/
Public comments due by November 5, 2008.
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Resources
• To order the video, Breaking Down the Language Barrier: Translating Limited English Proficiency into Practice– Contact the Department of Justice Civil
Rights Division’s Coordination and Review Section at (202) 307-2222 or [email protected]
– CDs and associated materials are available for free
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Questions
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For additional information, contact Cheri Wilson at:[email protected] or 410-502-6025.