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HSM5003 Field Research Red Group 1
Running Head: FIELD RESEARCH PROJECT LINGUISTIC SERVICES
Field Research Project:
The Role of Hospital Management in the Provision of Linguistic Services
Red Group: Jeri Hargrave, Robin Henson, Michael Lopez, and Connie Martinez
July 22, 2009
HSM 5003 Management of Health Service Organizations
Texas Woman’s University
HSM5003 Field Research Red Group 2
The Role of Upper Hospital Management in Providing Linguistic Services
Introduction
In 2008, 15% of the United States (U.S.) population, or approximately 45.5 million, was
comprised of Hispanic individuals. The percentage of Hispanics is forecasted to steadily
increase, and by 2050 the U.S. will be composed of a minority-majority, with non-Hispanic
whites becoming the minority (United States Census Bureau [USCB], 2008). As the U.S. adjusts
to this shift in demographics, the differences between culture and language intensify. This
enlarging gap is evident in our nation’s hospitals as healthcare organizations are unable to keep
up with cultural and language needs of this rapidly growing population. Cultural disparities exist
and have severe implications for patients, individuals and healthcare organizations (LaVeist,
Richardson, Relosa & Sawaya, 2008; Reynolds, 2004).
Purpose
Healthcare management must develop strategies that promote respect for cultural
differences and provide language support for their patients and employees within the healthcare
organizations (Reynolds, 2004). On June 19, 2009, Governor Rick Perry signed a bill that
establishes a committee to oversee Healthcare Interpreter Qualifications in the state of Texas
(Green, 2009). This bill is an important step because 38% of the U.S. Hispanic population
resides in Texas (Kaiser Family Foundation, 2008). This effort is one of many attempts that state
and local governments are making to close the gap between healthcare communication and
patients living in the U.S. with limited English proficiency (LEP) individuals. The purpose of
this field research project is to answer the question, “What is hospital management doing to
assure accurate translation of language for their Hispanic clientele?”
HSM5003 Field Research Red Group 3
Justification
When healthcare organizations do not effectively address language competencies,
negative patient, staff, and organizational outcomes can occur (Schenker, Wang, Selig, Ng &
Fernandez, 2007). Overall patient safety is compromised when hospital staff and the patient are
unable to communicate. Language barriers cause erroneous patient histories that often lead to
inaccurate diagnoses and treatments. Approximately 31 errors per patient occur when untrained
staff and families are used to interpret (Green, 2009). Patient education, discharge instructions,
and medication adherence are impeded when forms and labels are not translated. The various
degrees and combinations of these components prolong the patient length of stay, encourage
return hospital visits, and spend billions of excess healthcare dollars (Bethell et al., 2006; Jacobs,
Sadowski, & Rathouz, 2007; Reynolds, 2004).
Besides compromising patient care safety, language barriers result in hospital staffing
problems. Accessing translational services is a time consuming process, causing staff to often
avoid formal linguistic services. Instead there is an over-reliance on accessible bilingual hospital
unit staff to translate for them resulting in excess time burden on the bilingual staff and the
potential for translation inaccuracies. These factors combined with the employee’s fear of
liability contribute to staff dissatisfaction and high turn over rates (Jacobs et al., 2007).
In addition to patient and staff concerns, language barriers pose serious problems on the
organizational level. Paying additional staff and telephone language translation places an
additional cost burden on the hospital, and it is inconclusive whether these services result in
decreased organizational costs. The lack of state and federal regulations make it harder for
hospital administrators to justify the added costs; however, the organization must consider that
failure to provide patient interpretation can incur liability and undue patient harm. Failure for a
HSM5003 Field Research Red Group 4
healthcare organization to address cultural and language competence negatively influences the
perceptions of the general public and third party payers (LaViest et al., 2008).
Definition of Terms
1. Hispanic: “Hispanic individuals living in the United States include Cuban, Puerto Rican,
South or Central America, or other Spanish cultures of origin regardless of race” (USCB,
2008).
2. Limited English Proficiency (LEP): “ The inability to speak, read, write, or understand
English at a level that permits an individual to interact effectively with health care
providers or social service agencies” (Wilson-Stronks & Galvez, 2007, p.15).
3. Language competency: A process of effectively providing readily available, culturally
appropriate “oral and written language services to patients with LEP through such means
as bilingual/bicultural staff, trained medical interpreters, and qualified translators”
(Wilson-Stronks & Galvez, 2007, p.14).
4. Informal Linguistic Services: Utilization of patient services such as patient’s family
members, friends, as well as hospital staff to interpret and translate between two parties
that speak different languages (O’Leary, Federico, & Hampers, 2003).
5. Formal Linguistic Services: Utilization of individuals that have completed language
training programs, specific internship hours, and whose role is to specifically interpret
and translate between two parties that speak different languages. Usually handled by in-
house interpreters or can be outsourced and accessed through telecommunications
(Jacobs et al., 2007).
HSM5003 Field Research Red Group 5
Literature Review
Language and Interpretation Services
Many times hospital staff rely on other hospital volunteers and family members for
translation. Several studies reveal that family members or volunteer interpreters are more likely
to misinterpret, omit or add information, or insert personal values into the translation. Using
family minors to translate complicated, private, and sensitive health information is not
uncommon (O’Leary et al., 2003).
Some hospital institutions utilize formal linguistic services. There are many
considerations that must be made when a hospital hires a formal language service. The
organization must determine: what services are available, how many languages are provided, the
quality of interpreter raining, and the level of advanced communication technology. The speed of
the service should also be investigated and experts recommend that the language service should
have a response time of 25 seconds. Moreover, staff usability should be a high priority
(Greenbaum, 2004). Finally, language services are costly. The estimated cost of formal
interpretation is $234 per Spanish speaking patient intervention (Jacobs et al., 2007).
Hospital Friendly Environment
It is imperative that the hospital environment display its cultural friendliness through the
provision of signage in different languages and through the use of pictures instead of words. The
pharmacy should provide multi-lingual prescriptions and each unit should have the capability to
provide hospital brochures and patient discharge teaching in a variety of languages. Specific
units that have a greater influx of patients, such as the Emergency Room, should be provided
with a greater number of interpreters. Hospitals should also have a consistent and systematic
approach to collecting patient data for ethnicity, race, and primary language. This information
HSM5003 Field Research Red Group 6
should be analyzed and drive interventions that will reduce health disparities among minorities
(Pearson et al., 2007; Reynolds, 2004).
Hospital Administration’s Role
Dreaschlin and Myers (2007) posit that hospital management should have systems in
place to respond to the rapidly emerging differences in the culture and language of their patient
population. The commitment to adopt language competency should be highly visible to the
patients and to the staff. An established centralized program is recommended to support
consistent language services. This centralized program becomes the hub that collaborates with
education and risk management in order to identify and address staff and patient needs. In
addition, written policies must be developed to describe the types of language services that are
available, how patient’s can access these services, and the role of staff if a patient refuses a
language service (Wilson-Stronks & Galvez, 2007).
Research supports the hiring of diversity in the hospital organization workforce.
Currently, 85-90% of healthcare workforce in the United States is composed of non-minority
individuals (O’Leary et al., 2003). Patient surveys report a high satisfaction rate when minority
patients share their same culture and language with healthcare providers and hospital staff. In
turn, these patients have higher rates of trust, compliance, and improved outcomes of care
(Dreaschlin & Myers, 2007). Besides encouraging a diverse workforce, hospital management
should create financial incentives that will attract highly qualified language interpreters. These
upfront costs are proposed to have future cost-saving benefits (LaVeist et al., 2008; Pearson et
al., 2007).
HSM5003 Field Research Red Group 7
What is Actually Being Done in the U.S.?
The IOM and OMH
Together the Institute of Medicine (IOM) and Office of Minority Health (OMH) are
actively seeking ways to breakdown language barriers in U.S. healthcare. In a meta-analysis
conducted in 1999, Non-Hispanic whites were more likely than minorities to receive healthcare
services and necessary treatments for acute and chronic diseases, citing language as a major
contributing factor. Based on these findings, the IOM provides recommendations for healthcare
managers and system administrators to meet the objectives of providing high quality care to
minority populations. (Institute of Medicine [IOM], 2002). Through the IOM recommendations,
the OMH has established 14 national standards known as the Culturally and Linguistically
Appropriate Services (CLAS), which assures that cultural and language competence are
addressed throughout healthcare organizations. CLAS Standards 4-7 address the patient’s access
to language services and is a Federal requirements for all recipients of Federal funds, such as
Medicare (Appendix A). The provision of free language assistance, hospital signage, and written
instructions in the patient’s language are included in the standards (United States Department of
Health and Human Services [USDHHS], 2007).
Language Tools
There are various tools that a hospital can utilize to assess its cultural and language
competency. The Cultural Competency Assessment Tool for Hospitals (CCATH) is a free, 28-
item tool that assesses how well the hospital organization lines up with CLAS standards
(Dreaschlin & Myers, 2007). The Cultural Competency Organizational Assessment-360
(COA360) is a new tool developed to assess the cultural competency of organizations. The
COA360 is the first tool designed to assess organizations. Currently, only individuals are
HSM5003 Field Research Red Group 8
assessed. Like the CCATH, the COA360 is designed in accordance with the CLAS Standards
and recommendations from the IOM (LaViest et al., 2008).
Hospital, Language, and Culture Study
Through a California Endowment, 60 hospitals that represented 32 states, were chosen to
participate in the Hospital, Language, and Culture (HLC) study. The HLC was conducted by
Joint Commission and consisted of a one-day site visit and a 26-question pre-visit questionnaire
presented to hospital management and administration, human resources and clinical staff. The
HLC focused on the cultural competency of the nation’s hospitals. Language and translation
services were a key domain that the HLC evaluated. A six-item Management and Administration
Questionnaire was presented to hospital management to assess the role of administration in
cultural and language competency (see Appendix B).
Of the hospitals in the HLC survey, only 60% had a designated cultural and linguistic
department. Ninety percent reported in the questionnaire that they had written policies in place,
however, during the on-site visit the majority were unable to produce written language policies.
The majority of the hospitals had some type of budget money allocated for linguistic services,
however, only 30% reported language and culture as a specific line item. Of those surveyed, 55%
of the sample had designated executive-level staff that was directly responsible for culture and
language. The study did not list the findings about the cultural representation reflected in their
governing bodies (see Table 1). Based on these findings, the HLC report recommends that
specific action should be taken regarding language and hospital management:
Consider establishing a centralized program with executive-level reporting that
coordinates language services
HSM5003 Field Research Red Group 9
Hospital CEO’s and upper management should make their commitment to
linguistically appropriate care highly visible to staff and patients
Provision should be made for international multidisciplinary dialogues about
language issues to guide strategic planning
Financial incentives should be employed to recruit, develop, and retain qualified
healthcare interpreters
Future research to understand the motivating factors of hospital CEOs who
embrace linguistically appropriate care
The final comprehensive results of this study contributed to the development of the CLAS
national standards (Wilson-Stronks & Galvez, 2007, p. 8).
Methodology Criteria
For this project, the HLC Management and Administration Questionnaire was chosen.
This 6-item questionnaire assesses management’s role in addressing the linguistic needs of the
institution. The questionnaire was presented face-to-face or per telephone communication to
either the Cultural and Linguistic Service, QI, or Patient Safety departments within each hospital
(Wilson-Stronks & Galvez, 2007). See Appendix B for a listing of these questions.
Data Collection
This project utilized data from a convenience sample generated from five hospital
healthcare institutions: Atoka Memorial Hospital, Atoka, Oklahoma; Texas Hospital for
Advanced Medicine (formerly RHD) Dallas, Texas; Texas Health Presbyterian Hospital Denton,
Denton, Texas; Parkland Hospital, Dallas, Texas; Las Colinas Medical Center, Las Colinas,
Texas. Questionnaires were distributed to hospital administration, Patient Safety and Cultural
and Linguistic Service departments.
HSM5003 Field Research Red Group 10
Data Results
The Management and Administration Questionnaire was administered to five area
hospitals. Results can be found in Table 1. Although 100% surveyed indicated that they had
Table 1
Management and Administration Questionnaire Results
Question Responses % HLC
Results %
1. Formal Plans Developed
Yes 5 100 77
No
2. Services Driven by Laws
Very strongly 4 80 90
Strongly 1 20 10
Somewhat
Not strongly
Not at all
n/a
3. Allocated Operating Funds
Yes, specific line item/dedicated budget 2 40 30
Yes, incorporated with another budget 2 40 40
No 1
20 20
4. Established Language Department
Yes 2 40 60
No 3
60 40
5. Executive Level Staff
Yes 3 60 55
No 2
40 45
6. Governing Board Members
Yes 1 20 N/A
No 4 80 N/A
HSM5003 Field Research Red Group 11
strategic and formal business plans developed to meet the linguistic needs of their patient
population, only 40% of the organizations could physically locate these plans. Although the
majority of the hospitals (60%) do not have an established language service department, all but
one hospital stated that laws and regulations strongly influenced their provision of appropriate
linguistic services. Three of the five hospitals have a designated executive staff member assigned
to oversee linguistic competency plans and initiatives, including an executive vice-president, a
vice-president, and an individual that works directly under the CEO. Monies are allocated for
linguistic services in 80% of the institutions; however, only 2 are designated line items. Only one
hospital states its governing board adequately reflects the cultural diversity of the community in
which it serves.
As a side note, one of the five hospitals utilizes the In Touch ™ Critical Care Bed made
by Stryker. This bed was purchased by Texas Hospital for Advanced Medicine in May 2009.
The bed is able to verbalize pre-programmed questions and commands in 12 different languages.
It is not intuitive and it does not have the capacity to translate actual conversations between the
patient and the hospital staff. It is currently utilized in the Intensive Care Unit, and to some
degree, assists LEP patients with communication (see Appendix C).
Data Conclusion
The question, “What is hospital management doing to assure accurate translation of
language to their Hispanic clientele?” is not a simple one to answer. The research findings reveal
that hospital management perceives that they are taking a proactive role in managing the
language competency of their organization. The finding from this small convenient sample
reflect many similar findings from the HLC study (See Table 1). The five hospitals in this study
had a higher report of a formal language plan (100% vs. 77%), and executive level staff
HSM5003 Field Research Red Group 12
managing the linguistic plans and initiatives (60% vs. 55%). The HLC sample had a higher
report of established language services (60% vs. 40%) and 90% were “very strongly” driven by
the law than the study sample (80%). Both samples reported that 80% had some form of
allocated funds for linguistic services. Each study contained small sample sizes, so caution must
be made when interpreting these results. The findings do reveal, however, that executive leaders
have an important role in initiating, directing, and integrating language competency into the
culture of their organizations.
Through incorporation of the recommendations from the HLC study, there are three
things that management must do to assure accurate linguistic competency within their
organization. The first is to establish a centralized cultural and language department with the
intention of meeting CLAS standards. This department can develop written policies and utilize
tools such as the CCATH and the COA360 to evaluate the linguistic competency of the
organization and guide future language endeavors. The organization must utilize the findings
from these tools to set performance goals and systematically evaluate progress towards achieving
these goals. Secondly, management must make their commitment visible. They can do this by
encouraging diversity on their governing boards and encouraging the hiring of diverse employees
in an effort to better reflect their community. In addition, they must create financial provisions in
the budget for translators, appropriate signage and brochures, and staff training. Finally,
healthcare management should study other executives who have successfully embraced linguistic
competency within their institutions in order to gain insight and knowledge for success
(Dreaschlin & Myers, 2007; LaViest et al., 2008; Wilson-Stronks & Galvez, 2007).
HSM5003 Field Research Red Group 13
Appendix A
National Standards on Culturally and Linguistically Appropriate Services (CLAS)
Standards 4-7
HSM5003 Field Research Red Group 14
National Standards on Culturally and Linguistically Appropriate Services (CLAS)
Standards 4-7
Standard 4
Health care organizations must offer and provide language assistant services, including bilingual
staff and interpreter services, at no cost to each patient/consumer with limited English
proficiency at all points of contact, in a timely manner during all hours of operation.
Standard 5
Health care organizations must provide to patients/consumers in their preferred language both
verbal offers and written notices informing them of their right to receive language services.
Standard 6
Health care organizations must assure the competence of language assistance provided to limited
English proficient patient/consumers by interpreters and bilingual staff. Family and friends
should not be used to provide interpretation services (except on request by the patient/consumer).
Standard 7
Healthcare organizations must make available easily understood patient-related materials and
post signage in the languages of the commonly encountered groups and/or groups represented in
the service areas.
(USDHHS, 2007)
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Appendix B
Management and Administration Questionnaire
Hospitals, Language, and Culture use the Office of Minority Health (OMH) definition of
culturally competent healthcare: “services that are respectful of and responsive to the health
beliefs and practices, and cultural and linguistic needs of diverse patient populations.” For the
purposes of this project, “culture” refers primarily to characteristics of human behavior
associated with race, ethnicity, and religion. “Translation” refers to the conversion of spoken
communication from one language into another. Please answer the following questions honestly
based on your hospital’s services and administration. Remember, this is a baseline assessment
and there is no right or wrong answer.
1. Circle the correct answer; does the hospital specifically develop formal plans to meet the
cultural and linguistic needs of patients?
Cultural Needs Linguistic Needs Yes or No Yes or No
If yes, please check the types of plans that apply:
Strategic
Business
Budget
Other________________________________
Comments:
2. To what degree are your efforts to provide culturally and linguistically appropriate
services driven by laws and regulations?
Very strongly
Strongly
Somewhat
Not strongly
Not at all
Not applicable
Comments:
3. Does the hospital allocate operating funds for cultural and linguistic services?
Cultural Services
Yes, there is a specific line item or dedicated budget devoted to these services
Yes, but it is incorporated in another line item or budget
HSM5003 Field Research Red Group 16
No
Linguistic Services
Yes, there is a specific line item or dedicated budget devoted to these services
Yes, but it is incorporated in another line item or budget
No
Comments:
4. Does the hospital have an established multicultural or language services department,
project, or office?
Yes
No
Comments:
5. Does the hospital have executive level staff with direct responsibility for managing
cultural and linguistic competency plans and initiatives?
Cultural Competency
Yes
No
Linguistic Competency
Yes
No
A. If yes, please list his/ her title(s):
Comments:
6. Is the patient population’s cultural and linguistic diversity part of the criteria for choosing
governing board members?
Cultural Diversity
Yes
No
Linguistic Diversity
Yes
No
Comments:
HSM5003 Field Research Red Group 21
References
Bethell, C., Simpson, L., Read, D., Sobo, E.J., Vitucci, J., Latzke, B., et al. (2006). Quality and
safety of hospital care for children from Spanish-speaking families with limited
proficiency. Journal of Healthcare Quality: Promoting Excellence in Healthcare, 28(3),
3-16.
Dreaschlin, J.L., & Myers, V.L. (2007). A systems approach to culturally and linguistically
competent care. Journal of Healthcare Management, 52(4), 220-226.
Green, D. (2009). Texas Governor Rick Perry signs bill establishing a committee to oversee
health interpreter qualifications. Texas Association of Healthcare Interpreters and
Translators. Retrieved from http://www.pr.com/press-release/161004
Greenbaum, M.D. (2004). Selecting quality language services increases cultural competency.
Managed Healthcare Executive, 60.
Institute of Medicine. (2002 March). Unequal treatment: What healthcare system administrators
need to know about racial and ethnic disparities in healthcare: Report Brief. Unequal
Treatment: Confronting Racial and Ethnic Disparities in Health Care. Retrieved from
http://www.iom.edu/CMS/3704/4475/14973.aspx
Jacobs, E.A., Sadowski, L.S., & Rathouz, P.J. (2007). The impact of an enhanced interpreter
service intervention on hospital costs and patient satisfaction. Journal of General Internal
Medicine, 22, 306-311.
Kaiser Family Foundation. (2008). Texas: Total number of hospitals, 199-2007. State Health
Facts. Retrieved from http://www.statehealthfacts.org
HSM5003 Field Research Red Group 22
LaViest, T.A., Richardson, W.C., Richardson, N.F., Relosa, R., & Sawaya, N. (2008). The
COA360: A tool for assessing the cultural competency of healthcare organizations.
Journal of Healthcare Management, 53(4), 257-267.
O’Leary, S. C., Federico, S., & Hampers, L.C. (2003). The truth about language barriers: One
residency program’s experience. Pediatrics, 111(5), e569-e573. doi:
10.1542/peds111.5.e569.
Pearson, A., Srivastava, R., Craig, D., Tucker, D., Grinspun, D., Banjok, I. et al. (2007).
Systematic review on embracing cultural diversity for developing and sustaining a
healthy work environment in healthcare. International Journal of Evidence Based
Healthcare, 5, 54-91.
Reynolds, D. (2004). Improving care and interactions with racially and ethnically diverse
populations in healthcare organizations. Journal of Healthcare Management, 49(4), 239-
249.
Schenker, Y., Wang, F., Selig, S.J., Ng, R., & Fernandez, A. (2007). The impact of language
barriers on documentation of informed consent at a hospital with on-site interpreter
services. Journal of General Internal Medicine, 22, 294-299.
United States Census Bureau. (2008, September 8). Newsroom. Retrieved from
http://www.census.gov/Press-
Release/www/releases/archives/facts_for_features_specialeditions/012245.html
United States Department of Health and Human Services. (2007). National standards on
culturally and linguistically appropriate services (CLAS). The Office of Minority Health.
Retrieved from http://www.omhrc.gov/templates/browse.aspx?1v1=2&1v1ID=15
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