Moving the Needle on Experience by Embracing Patient Cultural and Linguistic

Diversity: A Hospital's Journey

Natasha Curtis, MA, CHI Language Access services Manager

Cheryl Christ-Libertin, DNP, CPNP-PC Evidence-based Practice Coordinator

PX 2014

Question

Little Johnny comes to the doctor…

Goals

•  Share strategies to raise staff awareness about current disparities in patient/family experience

•  Shape patient experience perceptions using various "communication" methods

•  Improve 360 experience (patient, clinician, staff) using tested best practices

§  A journey, not a destination

§  We do not claim to have arrived

§  It takes unrelenting commitment, intentionality, creativity, purposeful design, relationship-building and a good amount of action

§  Successes and challenges

Not alone…

“The success of any language access initiative is dependent on the commitment of the

health facility’s leadership. Leadership not only regulates organizational culture but also

provides the framework for planning, directing, coordinating and providing care.”

Language Access Services Advisory Committee

LISA A. AURILIO, MSN, RN, NEA-BC , Vice President Patient Services and Chief Nursing Officer

GEORGETTE CONSTANTINOU, Ph.D, Administrative Director, Pediatric Psychiatry & Psychology

DEBORAH G. GOULISH, LISW-S,  Director, Social Work

CHERYL C. LIBERTIN, MS, CPNP-PC, Nursing Clinical Research Coordinator,  Center for Excellence in Nursing Education and Research

ARIS ELIADES, PhD, RN, Director of Nursing, Center for Excellence in Nursing Education and Research

JULIANNE J. KLEIN, BSN, RN, Education Coordinator for Patient Family Education, Center for Excellence in Nursing Education and Research

ANNETTA PROVENS, MA Employee Relations Manager, Human Resources

MARY J. MARINO, MA, CCC-SLP, Director, Rehabilitation Services

About Akron Children’s •  Ranked a Best Children’s Hospital

by U.S. News & World Report

•  8th largest children’s hospital in country*

•  Magnet® Recognition for Nursing Excellence  

•  Largest pediatric provider in NE Ohio

•  2 hospital campuses

•  20+ primary care locations

•  60+ specialty location

•  Nearly 4,500 employees

•  750+ medical staff

*Source: 2012 Becker's Hospital Review

Cultural Diversity

§ Akron à refugee resettlement area

•  Over 2,500 refugees from Bhutan and Burma

•  Significant religious diversity within refugee populations

IMMIGRANT REFUGEE

Someone who has entered a new country to settle.

Someone who has left her/his country or is unable to return to it due to a well founded fear of persecution for reasons of race, religion, nationality, membership of particular social group or political opinion.

Choice Little or No Choice

(HREA, 2007)

Cultural Diversity

§ Nearby Holmes County à home to the largest Amish community in the world

Approximately 36,000

Linguistic Diversity

§  3 of 5 are languages of lesser diffusion

§  Significant number of families who speak indigenous languages.

LLDs Languages of Lesser Diffusion

LBDs Languages of Broader Diffusion

E.g. Nepali, Burmese, Karen

A language that has relatively few speakers in a defined geographic area.

Somali is a language of lesser diffusion in Arizona, but not in Minneapolis.

German is a language of lesser diffusion in Seattle, but not in Chicago.

Nuer is a language of lesser diffusion everywhere in the U.S.

E.g. Spanish, Arabic, French

“A language that has a relatively large number of

speakers in a defined geographic area.”

(Roat, 2012)

Linguistic Diversity

ü Nepali, almost as frequently encountered as Spanish

ü Other include: Burmese, Karen, Mon, Chin, American Sign Language, Arabic, Dutch, Ixil-Maya, K’iche and a variety of other indigenous languages.

ü  Literacy is very limited in the majority of these patient populations.

Experience Disparities…

Reasons to care about experience disparities

•  Experience Disparities cause both visible and invisible damage

The 360 Experience

& Culture

Culture: The lenses through which we view and interpret the world.

every interaction

is cross-cultural

(CCHCP, 2014)

"The quality of our decision-making is a function of the

quality of how well we understood the current state."

Jamie Flinchbaugh Transformational leadership. Entrepreneurial Excellence

The Strategy is simple…

First, We listen… Then, We empower…

“the current state”

The 360 Experience

Patient & Family

Provider & Staff

Interpreter/Patient Guide

The Hospital

The Community

The 360 Experience

The Patient and the Family

The Patient & The Family Experience – First, we listen…

The Patient & The Family Experience

1.  Understand the diversity of our patient population

2.  Identify challenges

3.  Communication

•  The use of competent and professional interpreters is required.

4.  Patient experience begins and extends outside of the hospital.

Ø  Designed a vision, a plan, to gradually close the gap

Ø  Worked on building trust

•  Learned about what was important to them and were present to support

Their food and food preparation

Wedding

Worked to integrate members of the

communities we serve into our system

The Patient & The Family Experience – Then, we empower…

•  Interpreters have been instrumental

an audible voice

•  Designed Language Access Program to stay relevant to the needs

Frequent “checking in”

DIAL Service – Empowering Families

Innovation

Transcreation

Sometimes, we have to think outside of the box

The talking box, that is…

The 360 Experience

The Provider & Staff

Cultural Diversity

§ Some service areas (esp. New Philadelphia) à home to a significant number of indigenous people from Guatemala

§ Increasing number of families from the Middle East. This, too, is a very heterogeneous group.

By Franklin Choate, Locust Pediatrics Care Group

Locust Pediatrics Care Group Dr. Peter Cooper White, Medical Director

The Provider/Staff Experience – First, we listen…

Barriers to good outcomes threaten the Provider & Staff experience.

•  Ineffective communication

•  Differences in cultural beliefs and perceptions

•  Low Literacy

•  Patient’s lack of familiarity with the system

Then, we empower…

• Provide competent language access services that result in effective communication

ü  Ease of access (OPI, VRI, F2F)

ü  Continuity – good for building relationships

•  Provide cultural competency training opportunities in a variety of ways

•  Engagement with the community through cultural/linguistic bridges

•  Point-To-Talk Karen Food Guide

Examples

Opportunities to learn about cultural competence

“I didn’t realize how easy it can be to communicate through a competent sign

language interpreter” (Physician response)

Cultural Competency Training

Residents

Example

Cultural Competence •  Families will continue to have their beliefs

and see the world through their lenses •  Evidence tells us that families will

experience: – More satisfaction with their care and care

providers – Greater adherence to treatment – Higher levels of trust If their cultural and health beliefs are: –  Elicited – Respected – Weaved into the plan of care

Cultural Competence | HOW? •  Ask questions

–  What do you think is making [Johnny] sick? –  What have you tried?

–  What do people in your community generally do for this? –  Do you have a traditional healer that you plan to consult? –  Are there any remedies that your community generally uses for this? If so… –  Can you bring it for us to see?

•  Respect beliefs –  That sounds interesting! –  How can I learn more about that?

•  Weave into the plan of care –  We usually treat children who present with these symptoms by… This is a very

effective approach that we know/expect will work for your child. –  Would you help us get him/her [to feel] better by doing [treatment plan]? –  If you happen to consult your traditional healer, please remember to share with me

their insight next time you come. I’d be curious to find out.

Examples

ALL HOSPITAL STAFF also learns about the importance of using

competent interpreters

This is why we do not use relatives or friends

Institutionalizing Cultural Competence and Empathy

• Movie Screenings

The 360 Experience

About The Interpreter/Patient Guide

Professional Medical Interpreter 1st

CONDUIT ROLE

Linguistic Bridge and Cultural Broker

Patient Guide

About Interpreter & Patient Guides

Patient Guide Role

In the Patient Guide Role, interpreters connect families to

care and provide continuity that begins prior to the visit

(scheduling), and extends after the visit (follow up)

Examples

1. Identifying need for preventive care and facilitating access.

2. Ensuring that preventive care services are used in a timely manner.

3. Avoiding lack of medication compliance by identifying barriers and bridging the access gap.

4. Catching opportunities for early detection

Community Liaison – The Missing Link

Selected from the target communities with the

guidance and leadership of the Interpreters/Patient Guides

Key Characteristics of our programs

Goal-oriented for

The families trust these individuals and their trust for our organization has grown as we built a link, a lifeline, that

begins and ends in their community

The 360 Experience

The Interpreter/Patient Guide

The Interpreter Experience – First, we listen…

•  Professional interpreters as partners

•  Qualified interpreters vs. untrained bilinguals

•  Often, this reality discourages them from continuing education

•  Availability of training

The Akron Children’s Language Access

Team

Quality is never an accident; it’s always the result of high intention, sincere effort; intelligent direction and skillful execution; it represents

the wise choice of many alternatives.

William A. Foster

The Interpreter Experience – Then, we empower…

•  Stress the importance of quality

• National Certification and Credentialing

•  Set clear goals and performance expectations

•  The “rules of the game”

•  Provide opportunities for development

The Interpreter Experience

•  Increase visibility

•  Show value and appreciation •  International Translator/Interpreter’s Day

•  Promote leadership •  The pyramid approach

•  Interpreter self-care

•  Streamline workflow •  iPad Minis – high efficiency scheduling

Showing appreciation

Subject: Amazing service!! I just wanted to tell you how much we appreciate Damber Subba!! He is amazing not only with the patients but in helping us out as an office!! We could not do our job effectively without him and he makes it a pleasure to work with him. He will often stop in our office just to check on a family’s follow up appointment or change a surgery date for them, he is so organized and efficient. Just wanted to let you know how much we appreciate him and his expertise!! Thank you!! Akron Children’s Hospital ENT Department Secretary

The 360 Experience

The Hospital

The Hospital – First, we listen…

• Safety

• Error Prevention

• Family-centered care

• Compliance

• Efficiency

• Cost-effectiveness

The Hospital – Then, we empower…

Competent Interpreters “The length of a hospital stay for LEP patients was significantly longer when professional interpreters were not used at admission or both admission/discharge.” (Lindholm, et. Al. 2012)

Culturally and Linguistically-appropriate care (CLAS)

Cost Effectiveness

Cost Effectiveness

$0.00 $10.00 $20.00 $30.00 $40.00 $50.00 $60.00 $70.00 $80.00 $90.00 $100.00

2010

2011

2012

2013

Cost Per Encounter – Karen Language

Cost Per Encounter

Interpreter as contractor

Interpreter was FTE 9 months/yr.

Cost Effectiveness

$-

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

$3.50

$4.00

2010 2012 2014

OPI Cost

OPI Cost

The 360 Experience

The Community

Building Community Partnerships

The Refugee

Health Task Force

•  2 surrounding Adult Hospitals

•  2 Academic Institutions of Higher Education

•  Public Health

•  Refugee Resettlement Agency

•  Social Services Agencies

•  Mental Health Services Agencies

•  Refugee Community Leaders

In Short In our journey to address Experience Disparities we •  Invested time and effort in understanding the

communities we serve.

•  Engaged members of those communities in our system

•  Intentionally designed a vision around the 360 Experience

•  Partnered with other community stakeholders

•  Were willing to explore unconventional solutions to common problems

Q&A

References Curtis, N. (2013, October 10). Interpreter, Friend or foe? Practical tips for

providing excellent care to patients and families who communicate in languages other than English. Kids 2013: Best Practices Today and Beyond. Conducted from Akron Children’s Hospital, Akron, OH.

Human Rights Education Associates. (2007). In Refugees and Displaced Persons.

Key Terms. Retrieved March 7, 2014 from http://www.hrea.org/index.php?base_id=153.

Lindholm M, Hargraves JL, Ferguson WJ, et al. Professional language

interpretation and inpatient length of stay and readmission rates. J Gen Intern Med. 2012 Apr 18. [Epub ahead of print]

Roat, C. E. (2012, March 28). Addressing Language Barriers When Serving

refugee Patients [Webinar]. Retrieved from http://tinyurl.com/knnur9o The Cross Cultural Health Care Program. (2014). Connecting to Care Patient

Guide Training Program. Seattle:, WA: CCHCP

References University Hospital Southampton NHS Foundation Trust. (Producer). (2012).

Interpreter (Royal College of Obstetricians and Gynaecologists) [Video webcast]. Retrieved from https://vimeo.com/55940134

Author Last Name, First Initial. Second Initial, & Author Last Name. First Initial.

Second Initial. (Year, Month Day). Title of webinar [Webinar]. In LLC Webinar Series. Retrieved from URL