Improving health care for foreigners in Japan:Stories, Data and Policy Models

Julia Puebla Fortier, Director, DiversityRx

Julia Puebla Fortier

Executive Director

DiversityRx – Resources for Cross Cultural Health Care

www.diversityRx.org

DiversityRx:Improving health care for a diverse world

Policy development

Research

Information dissemination

Education and training

Working with:

Hospitals and health departments

Universities

Philanthropic foundations

Government agencies

International organizations

Medical tourists

Foreign bridesInternational students

Expat professionals

Migrants Indigenous peopleForeign workers

RefugeesMinorities

Diversity in Japan

The number of foreign residents has more than doubled since the 1990s:

China 647,230South Korea/DPRK 526,575Philippines 206,769Brazil 185,644Vietnam 61,920U.S.A.49,216Peru 48,976Thailand 40,699Taiwan 29,466 Nepal 27,584Indonesia 26,171

Japan’s future diversity

Increase Japan’s participation in global marketplace

Prepare Japan for influx of foreign visitors for 2020 Olympics

Government goal to double number of tourists to 20 million

Build medical tourism industry

Goal to increase to 30 million by 2030 the number of visitors coming to Japan for medical treatment.

Expand international participation in Japanese university education

In 2012, there were more than 137,000 foreign students and the current government aims to double these numbers by 2020.

Economic and Political Initiatives

Getting health care in Japan

Emergency Room visit:Foreign patient perspective

Big red sign at entrance, Japanese only – Emergency Room?

Reception desk – many signs, nothing in English

Intake form in Japanese with English translation

iPhone and Google Translate to talk to receptionist

Nurse triage – no English. Called friend on phone

Doctor and x-ray technician speak English

Discharge forms in Japanese, another doctor to translate

Translated map on the way out

The impact of language barriers on patient

behavior

How the patient feels

Disempowered, frustrated

Overwhelmed by everyday life -- don’t want to take on the health system too

Fear interactions I don’t understand, from the first phone call to the actual visit

Can’t think clearly in the moment, don’t ask questions

Don’t want to bother anyone -- just try to be polite and deferential

Grateful for anything that makes sense

How the patient acts

Doesn't do routine care

Doesn't do follow-up tests

Puts off going to the doctor until it can’t be avoided

Doesn’t know how to find a good doctor

Goes to a doctor just because they speak my language

Not assertive, doesn’t try to discuss options

When they get poor care, don’t report it - just don’t go back

Stories are nicebut data affects policy

and social change

National survey of foreign patients

1. To analyze the experience of foreign residents and visitors about

their experience accessing health care

interactions with health care providers and staff

any cultural or linguistic barriers to effective communication and delivery of health care services.

2. To identify opportunities and challenges to improving the health care experience of foreigners in Japan.

Purpose

Survey methods

Pretest development and testing in Kobe (Spring 2014)

National online survey (October – December 2014)

Survey:

Survey language: English. Future languages dependent on financial and technical resources

39 substantive questions

8 demographic questions

Request for interview

Survey target audience

Foreign-born residents

Expatriate (short-term) professionals and their families

Short-term/migrant workers

International students and educators

Medical tourists

Sample questions

Did you use an interpreter during this visit to talk to the medical provider or staff?

If an interpreter was not provided by the office or hospital, did you bring someone else to interpret for you when you talked to the provider?

If you did not have an interpreter but you needed one, do you think this negatively affected the quality of care you received?

Did the provider give you an easy to understand explanation about your condition and the next steps for your treatment?

If a prescription was provided, did you understand what the medication was, how to take it, and any possible side effects?

If the provider ordered additional blood tests, x-rays, or other tests, did she or he explain the reason?

Did the provider answer all your questions to your satisfaction?

Language issues Doctor-patient communication

Survey responses (486 total)(Sample preliminary data, please do not quote)

57 percent delay getting care because of language or cultural difficulties

74 percent prefer to communicate in English

60 percent needed an interpreter sometimes or chose an English speaking doctor

80 percent of those who needed an interpreter but didn’t have one said it may have negatively affected the quality of care

55 percent said the doctor did not give or only gave a somewhat clear explanation about their condition and treatment

58 percent said their questions concerns were not completely addressed by the doctor

Many stories to tell: Qualitative responses

High number of qualitative responses—

239 answers to “Did any cultural issues arise during the consultation that might have had an impact on your communication or negotiation with the provider? Please describe.”

259 respondents indicated a willingness to be contacted for further phone/email interview.

Value of the survey to nurses

Shows what experiences foreign patients have, and how nurses can respond better to their needs

Could be used to evaluate patient care experience in hospitals

Results could be used to promote organizational changes that better support foreign patients

How to improve services to foreign patients:

The role of standards

Global context

U.S. – Civil Rights Law, CLAS Standards, state laws, Joint Commission, NCQA, National Quality Forum, health reform

European Union – Migrant Friendly Hospital demonstration and Amsterdam declaration, individual country policies, Council of Europe

Australia and New Zealand standards

Global – WHO Health Promoting Hospitals Task Force, WHO Global Consultation on Migrant Health

Laws and regulations, standards, resolutions, performance measures, accountability frameworks

United States CLAS Standards(2000, 2013)

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care

The National CLAS Standards are designed to

advance health equity

improve quality

help eliminate health care disparities

by establishing a blueprint for health and health care organizations to respond to cultural and linguistic issues that arise in health care.

CLAS Standards

Principal Standard 1. Provide effective, equitable, understandable,

respectful, and quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs

CLAS Standards: Theme 1

Governance, Leadership, and Workforce 2. Promote and sustain governance and leadership

that promotes CLAS and health equity

3. Recruit, promote, and support a diverse governance, leadership, and workforce

4. Educate and train governance, leadership, and workforce in CLAS

CLAS Standards: Theme 2

Communication and Language Assistance

5. Offer communication and language assistance at no cost

6. Inform patients of the availability of language assistance

7. Ensure the competence of people providing language assistance

8. Provide easy to understand information and signage

CLAS Standards: Theme 3

Engagement, Continuous Improvement, and Accountability

9. Infuse CLAS goals, policies, and management accountability throughout the organization’s planning and operations

10. Conduct organizational assessments of CLAS activities

11. Collect and maintain demographic data

CLAS Standards: Theme 3

Engagement, Continuous Improvement, and Accountability

12. Conduct assessments of community health assets and needs

13. Partner with the community to plan and implement services for diverse populations

14. Create conflict and grievance resolution processes that address cultural and linguistic issues

15. Communicate the organization’s progress in implementing and sustaining CLAS

Reasons to adopt standards

Respond to demographic changes.

Highlight the special needs of foreign populations

Improve the quality of services and primary care outcomes.

Benefit from a clear organizational framework

Gain a competitive edge in the market place.

Decrease the likelihood of liability/malpractice claims.

Keys to success

Top leadership support

Educating all staff

Financial resources

Incorporate into other strategies (quality improvement, patient safety, improving outcomes)

Show successful models

Step by step approach

The need for advocacy and education

Advocating culturally and linguistically responsive services in the United States: Who

Representatives of foreign/non-English speaking populations

Medical interpreters

Health care providers that care for foreign populations

Policymakers (politicians and health department staff)

Researchers

Foundations

Journals

Advocating culturally and linguistically responsive services in the United States: How

Human right of equal access to health care

Impact of language/cultural barriers on health care delivery

Legal and financial consequences of medical errors

Good practice and policy models

Improve quality of care

Reduce health disparities

Advocating for culturally and linguistically responsive care in Japan: health organizations

Educate all working health care staff

Change hospital policy and practices

Hire bilingual staff, patient advocates

Train professional and volunteer interpreters

Use telephone interpretation services

Advocating for culturally and linguistically responsive care in Japan: policymakers

Human rights

Quality of care

Reduce medical errors

Attract foreign patients through medical tourism

Leadership from nursing administrators and educators

Educate working nurses and future nurses about the needs of foreign patients, cross cultural health care, and how to work with interpreters

Encourage second-language study by Japanese nurses, and support the integration of foreign nurses

Promote evaluations of foreign patient care experiences in health care organizations

Promote culturally and linguistically responsive care at the administrative level as a patient safety and clinical efficiency issue

Develop nursing practice guidelines for working with foreign patients

Raise awareness

Document good practices

Speak at health care conferences

Conduct research and publish journal articles

Write about what goes wrong in newspaper and magazine articles

Nurses are the most important advocates for patients and their

families. Your sensitivity and concern for quality care can

benefit all patients, where ever they come from.

ご静聴ありがとうございました

For more information:

Foreign patient survey:www.diversityRx.org/health-care-Japan

CLAS standards and blueprint:http://1.usa.gov/1hS8SAv

Transcultural Nursing Society practice standards:http://bit.ly/1ansoFM

Contact:(English) Julia Puebla Fortier, rcchc@aol(Japanese) Rie Ogasawara, ogaoga616@yahoo.co.jp