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

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

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.

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.

Federal Mandates and Legislation

• Two major impediments to providing language services are:

– Lack of availability of qualified, medical interpreters, and

– Inadequate funding

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.

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.

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.

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.

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.

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.

Patient Safety and Healthcare Quality

• Untrained interpreters are more likely to commit errors in interpretation that can lead to adverse clinical consequences.

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.

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."

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.

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?

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.

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

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.

Best Practices: The Johns Hopkins Hospital

Best Practices: The Johns Hopkins Hospital

Best Practices: The Johns Hopkins Hospital

• Johns Hopkins International has translated certain patient education materials into various foreign languages.

Best Practices: The Johns Hopkins Hospital

Best Practices: The Johns Hopkins Hospital

• In addition, Patient Education materials are available in English and Spanish in Micromedex CareNotes™.

Best Practices: The Johns Hopkins Hospital

Resources

• National Standards on Culturally and Linguistically Appropriate Services (CLAS)http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15

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

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/

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

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

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

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

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 crt.lep@usdoj.gov

– CDs and associated materials are available for free

Questions

For additional information, contact Cheri Wilson at:cwilso42@jhmi.edu or 410-502-6025.