Advancing Effective Communication, Cultural Competence, and Patientand Family-Centered Care: A Roadmap for Hospitals Christina L. Cordero, PhD, MPH Associate Project Director Department of Standards and Survey Methods Division of Healthcare Quality Evaluation The Joint Commission Connecticut Multicultural Health Partnership Language Access Services A Symposium for Health Administrators May 16, 2011
Communication and Health Care Communication is the cornerstone of patient safety Health care is communication-dependent and accurate information is needed for several important processes Direct communication can be affected by: Language Culture Hearing or Visual Impairment Health Literacy Cognitive Limitation Intubation Disease (ALS, Stroke) 2
Communication and Sentinel Events Joint Commission s Sentinel Event Database Voluntary reports January 1995 current sentinel event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase or the risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. 3
Communication and Sentinel Events Joint Commission s Sentinel Event Database Voluntary reports January 1995 current Detailed root cause analysis for 843 Sentinel Events out of 1400 total events accepted between July 2006 and October 2008 Communication identified as a root cause for 533 Sentinel Events reported to The Joint Commission 4
Root Cause Sub-Categories of Communication Copyright, The Joint Commission Sub-categories of Communication as a Root Cause of Sentinel Events (2006-2008) Electronic Communication With Administration Written Communication With Patient or Family Oral Communication With Physician Among Staff 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% Note: Percentages based on sentinel events in which communication was found as the primary root cause (533 events) 5
Joint Commission Support for Effective Communication Copyright, The Joint Commission Joint Commission Accreditation Standards Existing standards New standards for patient-centered communication Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals 6
Existing Standards Standard HR.01.04.01 The hospital provides orientation to staff. EP 5: The hospital orients staff on the following: Sensitivity to cultural diversity based on their job duties and responsibilities. Completion of this orientation is documented. Standard HR.01.05.03 Staff participate in ongoing education and training. EP 5: Staff participate in education and training that is specific to the needs of the patient population served by the hospital. Staff participation is documented. 7
Existing Standards Standard LD.02.01.01 The mission, vision, and goals of the hospital support the safety and quality of care, treatment, and services. Standard LD.04.01.01 The hospital complies with law and regulation. Standard LD.04.03.09 Care, treatment, and services provided through contractual agreement are provided safely and effectively. EP 4: Leaders monitor contracted services by establishing expectations for the performance of the contracted services. 8
Existing Standards Standard PC.02.03.01 The hospital provides patient education and training based on each patient s needs and abilities. EP 1: The hospital performs a learning needs assessment for each patient, which includes the patient s cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication. Standard PC.02.02.03 The hospital makes food and nutrition products available to its patients. EP 9: When possible, the hospital accommodates the patient s cultural, religious, or ethnic food and nutrition preferences, unless contraindicated. 9
Existing Standards Standard RC.02.01.01, EP 1 The medical record contains the following demographic information: The patient s language and communication needs Standard RI.01.01.01 The hospital respects, protects, and promotes patient rights. EP 5: The hospital respects the patient s right to and need for effective communication. EP 6: The hospital respects the patient s cultural and personal values, beliefs, and preferences. EP 9: The hospital accommodates the patient s right to religious and other spiritual services. 10
Existing Standards Standard RI.01.02.01 The hospital respects the patient's right to participate in decisions about his or her care, treatment, and services. Standard RI.01.01.03: The hospital respects the patient s right to receive information in a manner he or she understands EP 1: The hospital provides information in a manner tailored to the patient s age, language, and ability to understand. EP 2: The hospital provides interpreting and translation services, as necessary. EP 3: The hospital communicates with the patient who has vision, speech, hearing, or cognitive impairments in a manner that meets the patient s needs. 11
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care Copyright, The Joint Commission Multidisciplinary Expert Advisory Panel ~700 nominations received, 26 members chosen Develop accreditation standards for hospital program Incorporate issues such as diversity, culture, language, and health literacy into current standards or draft into new requirements Develop guidance monograph for field Collaboration with National Health Law Program (NHeLP) Include implementation examples, practices, resources, and other how to information Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals 12
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care Copyright, The Joint Commission Build on previous studies, research projects, and evidence from current literature Focus on broader elements of communication, cultural competence, and patient- and familycentered care Gap analysis with OMH CLAS standards Released proposed requirements for field review Revisions based on feedback from field and other stakeholders 13
Patient-Centered Communication Standards Qualifications for language interpreters/translators Identify communication needs Address communication needs Provide language services Collect preferred language data Collect race and ethnicity data Allow patients access to a support individual Ensure care free from discrimination 14
Implementation Plan for Standards Standards approved in December 2009 Released to field in January 2010 Standards will appear in 2011 Hospital manuals Surveyors will evaluate compliance with standards Findings will not affect the accreditation decision Implementation pilot phase to collect feedback Inclusion in accreditation decision no earlier than 2012 RI.01.01.01, EPs 28 and 29 will be implemented July 1, 2011 15
Qualifications for Interpreters Standard HR.01.02.01 The hospital defines staff qualifications. Element of Performance (HR.01.02.01) 1. The hospital defines staff qualifications specific to their job responsibilities. NEW Note 4: Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964. (Inclusion of these qualifications will not affect the accreditation decision at this time.) 16
Qualifications for Interpreters Issues to Consider: The Joint Commission does not require any certifications for language interpreters or translators and does not specify minimal requirements for education or training. The goal of Note 4 is to provide examples of the types of qualifications that should be required for individuals that provide language interpreting and translation services and to discourage hospitals from relying on untrained individuals to provide language services as their primary option to meet communication needs. 17
Effective Patient-Provider Communication Copyright, The Joint Commission NEW Standard PC.02.01.21 The hospital effectively communicates with patients when providing care, treatment, and services. Note: This standard will not affect the accreditation decision at this time. Rationale This standard emphasizes the importance of effective communication between patients and their providers of care, treatment, and services. Effective patient-provider communication is necessary for patient safety. Research shows that patients with communication problems are at an increased risk of experiencing preventable adverse events, and that patients with limited English proficiency are more likely to experience adverse events than English speaking patients. 18
Effective Patient-Provider Communication Copyright, The Joint Commission Effective communication The successful joint establishment of meaning enabling patients to participate actively in their care To be truly effective, communication requires a two-way process (expressive and receptive) in which messages are negotiated until the information is correctly understood by both parties. Successful communication takes place only when providers understand and integrate the information gleaned from patients, and when patients comprehend accurate, timely, complete, and unambiguous messages from providers in a way that enables them to participate responsibly in their care. 19
Effective Patient-Provider Communication Copyright, The Joint Commission Elements of Performance (PC.02.01.21) NEW 1. The hospital identifies the patient s oral and written communication needs, including the patient s preferred language for discussing health care. Note 1: Examples of communication needs include the need for personal devices such as hearing aids or glasses, language interpreters, communication boards, and translated or plain language materials. Note 2: This element of performance will not affect the accreditation decision at this time. NEW 2. The hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient s oral and written communication needs. Note: This element of performance will not affect the accreditation decision at this time. 20
Right to Effective Communication Copyright, The Joint Commission Standard RI.01.01.03 The hospital respects the patient s right to receive information in a manner he or she understands. Elements of Performance (RI.01.01.03) 2. The hospital provides language interpreting and translation services. NEW Note: Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population. 3. The hospital provides information to the patient who has vision, speech, hearing, or cognitive impairments in a manner that meets the patient s needs. 21
Collection of Patient-Level Data Copyright, The Joint Commission Standard RC.02.01.01 The medical record contains information that reflects the patient s care, treatment, and services. Element of Performance 1. The medical record contains the following demographic information: - The patient s name, address, date of birth, and the name of any legally authorized representative - The patient s sex - The patient s communication needs, including preferred language for discussing health care NEW Note: If the patient is a minor, is incapacitated, or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision-maker, or legally authorized representative is documented in the medical record. 22
Collection of Patient-Level Data Copyright, The Joint Commission Standard RC.02.01.01 The medical record contains information that reflects the patient s care, treatment, and services. Element of Performance NEW 28. The medical record contains the patient s race and ethnicity. Note: This element of performance will not affect the accreditation decision at this time. 23
Collection of Patient-Level Data Issues to Consider: Joint Commission standards do not specify categories for the collection of race and ethnicity data. However, many state reporting entities and payors do specify these requirements. Additionally, the Roadmap for Hospitals includes suggested race and ethnicity categories from the Office of Management and Budget and the Institute of Medicine. 24
Access to a Support Individual Standard RI.01.01.01 The hospital respects, protects, and promotes patient rights. Element of Performance NEW 28. The hospital allows a family member, friend, or other individual to be present with the patient for emotional support during the course of stay. Note 1: The hospital allows for the presence of a support individual of the patient s choice, unless the individual s presence infringes on others rights, safety, or is medically or therapeutically contraindicated. The individual may or may not be the patient s surrogate decision maker or legally authorized representative. Note 2: This element of performance will not affect the accreditation decision at this time.* *RI.01.01.01, EP 28 will be implemented July 1, 2011 25
Access to a Support Individual Issues to Consider: The hospital is not required to provide items such as chairs, beds, meal vouchers, or any other accommodations for the support person. The goal of EP 28 is focused on the hospital allowing for the presence of a patient s support person. 26
Non-Discrimination in Care Standard RI.01.01.01 The hospital respects, protects, and promotes patient rights. Element of Performance NEW 29. The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression. Note: This element of performance will not affect the accreditation decision at this time.* *RI.01.01.01, EP 29 will be implemented July 1, 2011 27
R 3 Report Rationale and Research Download the R 3 Report for free: http://www.jointcommission.org In-depth look at rationale behind new standards, National Patient Safety Goals and performance measures Documents supporting research and scientific data behind the development of requirements First issue of R 3 Report focuses on the patientcentered communication standards for hospitals 28
Roadmap for Hospitals Inspire hospitals to integrate effective communication, cultural competence, and patient- and family-centered care into system of care Recommended issues to address to meet unique patient needs, above and beyond standards Implementation examples, practices, and how to information Download Roadmap for Hospitals free at: http://www.jointcommission.org/advancing _Effective_Communication 29
Roadmap for Hospitals - Chapters Structured around main points in care continuum Admission Assessment Treatment End of Life Discharge and Transfer Organization Readiness chapter as a foundation Leadership Data Collection and Use Workforce Provision of Care, Treatment, and Services Patient, Family, and Community Engagement 30
Recommendations from the Roadmap Effective Communication Develop a system to provide language services (supporting New PC.02.01.21, existing RI.01.01.01, RI.01.01.03) Determine the types of services needed (bilingual care providers, language interpreters and translators) Identify the methods used to provide services (in-person, telephonic, video) Offer a mixture of language services to ensure coverage Provide translated written documents for frequently encountered languages Train staff on how to access services and work with interpreters Inform patients of their right to receive language services Note the use of language services in the medical record Monitor the use of language services 31
Recommendations from the Roadmap Ensure competence of individuals providing language services Define qualifications for language interprets and translators (supporting New Note to HR.01.02.01) Consider including certification for sign language interpreters Conduct assessment of language proficiency for interpreters and translators (supporting existing HR.01.06.01) Promote ongoing training and education (supporting existing HR.01.05.03 ) Review qualifications for contracted language services or external vendors (supporting existing LD.04.03.09) Refrain from relying on untrained individuals (family or friends) to provide language services Consult resources for additional guidance (NCIHC, ATA) 32
Recommendations from the Roadmap Identify the patient s preferred language for discussing health care (supporting New PC.02.01.21) Use language cards or tools to identify language Note language in medical record (supporting existing RC.02.01.01) Use standardized language categories to collect data Use aggregated patient-level language data to develop or modify services, programs, initiatives Identify whether the patient has a sensory or communication need (supporting New PC.02.01.21, existing RC.02.01.01) 33
Recommendations from the Roadmap Communicate information about unique patient needs to the care team Ensure data can transfer to clinical database for use at point of care Tailor the informed consent process and patient education materials to meet patient needs (supporting existing RI.01.03.01. PC.02.03.01) Integrate health literacy strategies into patient discussions and materials (supporting New PC.02.01.21, existing RI.01.01.03) Identify follow-up providers that can meet unique patient needs 34
Recommendations from the Roadmap Cultural Competence Develop a system to collect patient race and ethnicity information (supporting New RC.02.01.01, EP 28) Modify paper or electronic medical records (may involve adding new fill-in spaces, fields, drop-down menus) Use standardized categories to collect data Train staff to collect race and ethnicity data Use aggregated patient-level data to develop or modify services, programs, initiatives to meet population needs Use available population-level demographic data to help determine the needs of the community Use available demographic data, information on health literacy levels, data on sexual orientation Conduct focus groups or interview community leaders to identify changes in community needs/demographics 35
Recommendations from the Roadmap Identify and accommodate cultural, religious, or spiritual beliefs or practices that influence care (supporting existing RI.01.01.01, EPs 6 and 9) Respect the patient s needs and preferences for modesty and privacy Determine if the patient uses any complementary or alternative medicine or practices Consult a professional chaplain, if available, to complete a spiritual assessment Identify dietary needs or restrictions that affect care (supporting existing PC.02.02.03, EP 9) Identify if the patient s religious or spiritual beliefs or customs require or forbid eating certain foods Note the dietary needs or restrictions in the medical record and communicate to staff and food service 36
Recommendations from the Roadmap Target recruitment efforts to increase the pool of diverse and bilingual candidates Advertise job opening in targeted foreign-language publications and other media Define policies that accommodate dress, daily religious practices of local workforce, when possible Support training and career development for nonclinical staff Develop relationships with local community colleges to develop volunteer, work-study, and internship programs Encourage transition of ESL students into health care careers by partnering with technical colleges, adult literacy programs 37
Recommendations from the Roadmap Incorporate communication, cultural competence, and patient- and family-centered care issues into staff training curricula Use various methods (in-service, grand rounds, case studies, DVD courses, online modules) Provide training opportunities at intervals throughout year (supporting existing HR.01.05.03) Incorporate training into performance expectations (supporting existing HR.01.07.01) Support current efforts to address these issues Encourage staff to improve overall communication skills (patient-provider, provider-provider) Address unique patient needs in relevant policies and procedures Inform staff of federal and state laws and regulations that support these issues (supporting existing LD.04.01.01) 38
Recommendations from the Roadmap Identify staff concerns or suggested improvements for providing care that meets patient needs Conduct a staff survey to evaluate staff s experiences using language services and auxiliary aids, barriers to accommodating cultural and religious needs (supporting New PC.02.01.21) Create an environment that welcomes diverse staff and patients Provide support for staff caucuses or special interest groups to discuss cultural, religious, disability, LGBT concerns Promote staff discussion around challenges and barriers to providing care Protect staff from discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression (supporting New RI.01.01, EP 29) 39
Recommendations from the Roadmap Patient- and Family-Centered Care Begin the patient-provider relationship with an introduction Introduce members of the care team Ask patient about preferred name Ask about cultural considerations for addressing patient and family Identify and address patient mobility needs Make sure any needed assistive devices (service animal, cane, walker, wheelchair) is available to patient Identify whether specialized equipment is needed 40
Recommendations from the Roadmap Create an environment inclusive of all patients Incorporate concepts of universal design Provide a diverse collection of magazines and brochures in the waiting areas Make sure navigational signage can be understood by the patient population Ask the patient to identify a support person (supporting New RI.01.01.01, EP 28) Explain the purpose of the patient s support person, including limitations Make staff aware that the patient has chosen a support person Involve patients and families in the care process and discharge/transfer planning and instruction 41
Recommendations from the Roadmap Collect feedback from patients, families, and the surrounding community Make sure complaint resolution system and patient surveys can accommodate feedback from patients and families with communication needs Invite patients and families to participate in focus groups, advisory councils Engage local adult literacy or adult basic education programs to provide feedback on written materials Share information with the community about hospital efforts to meet unique patient needs Engage the community through public events and health fairs Post information about available services, programs, initiatives on hospital web site 42
Roadmap for Hospitals - Appendices A: Checklist of all issues to address B: Existing Joint Commission requirements supporting effective communication, cultural competence, and patient- and family-centered care C: New Joint Commission standards for patientcentered communication Explanation of revision/addition Self-assessment guidelines Practice examples D: Laws and regulations E: Resource guide 43
Joint Commission Efforts Past and Present Copyright, The Joint Commission Research Study: Hospitals, Language, and Culture: A Snapshot of the Nation Health Equity and Meeting the Needs of the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community Public Policy White Paper: What Did the Doctor Say?: Improving Health Literacy to Protect Patient Safety Speak Up Initiative 44
Hospitals, Language, and Culture: A Snapshot of the Nation (HLC) Copyright, The Joint Commission Cross-sectional qualitative study Three Research Questions: 1. What are the challenges hospitals face providing care to diverse patient populations? 2. What are hospitals doing to address these challenges? 3. Are there any promising practices that can be replicated to improve care? 45
HLC Sample Hospitals (n=60) Rural: 15 Region (representing 32 states) Northeast Midwest West 10 12 21 South 17 100-299 beds: 18 25-99 beds: 10 Non-profit:32 Urban: 35 Public: 15 Teaching/Academic: 22 300+ beds: 32 46
Exploring Cultural and Linguistic Services in the Nation s Hospitals: A Report of Findings Copyright, The Joint Commission Released in March 2007 Download a free copy of the report on HLC website Provides an overview of the HLC study Detailed methodology Site visit protocol Recommendations for hospitals, policymakers, and researchers Download the Report of Findings free at: http://www.jointcommission.org/advancing_ Effective_Communication 47
One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations Copyright, The Joint Commission Released April 2008 Download a free copy of the report on HLC website Thematic framework derived from current practices in 60 hospitals Self-assessment tool to tailor initiatives to meet the needs of diverse patient populations Download One Size Does Not Fit All free at: http://www.jointcommission.org/advancing_ Effective_Communication 48
Additional HLC Projects A study to help understand what drives some hospital CEOs to embrace language, culture, and health literacy improvement initiatives (Sept/Oct JHM) Video with Office for Civil Rights to support language access in health care organizations - Improving Patient-Provider Communication: Joint Commission Standards and Federal Laws (on website) Ongoing research on the experience of Juan Lopez, a limited English proficient patient, at 60 hospitals across the nation (in preparation) 49
Through the Eyes of a Patient 60-year-old Mexican immigrant Limited English proficient Meet Juan Lopez Limited experience with the U.S. health care system 12-year-old English-speaking daughter Juanita Suffered appendicitis Visits Emergency Department for temporary pain relief Cultural health belief 50
Staff Juan Lopez Encounters Triage nurse Emergency department physician Emergency department nurse Radiology tech Medical surgery unit for recovery 51
How would you communicate with Juan Lopez? Luckily we have a lady in housekeeping who speaks Spanish. 90% of our foreign speakers speak that language and she is able to help us Triage nurse Hospitals, Language, and Culture Study. The Joint Commission, 2010. 52
How would you communicate to Juan Lopez that he needs surgery? First of all, I would probably use my little board or notepad, and I would write in English to see if he understands the language. If that is not the case, what I usually do is maybe by some form of sign language try to explain to him that he has severe pain in his abdomen and he probably needs an operation. The other thing I could show him is maybe pictures of a surgeon where he probably has to open up the abdomen to perform the procedure. Emergency Department Physician Hospitals, Language, and Culture Study. The Joint Commission, 2010. 53
Meeting the Needs of LGBT Patients LGBT Stakeholder Meeting: To promote effective communication, cultural competence, and patient-and family-centered care for lesbian, gay, bisexual, and transgender (LGBT) patients and families by bringing together stakeholders to identify practices and articulate implementation processes. Field guide/toolkit addressing LGBT health care in hospitals Increased awareness among health care providers, consumers, and policymakers 54
Public Policy White Paper: Health Literacy Recommendations Download this report for free at: http://www.jointcommission.org/advan cing_effective_communication Recommendation 1: Make effective communications an organizational priority to protect the safety of patients Recommendation 2: Incorporate strategies to address patients communication needs across the continuum of care Recommendation 3: Pursue policy changes that promote improved practitioner-patient communications 55
Speak Up Initiative Download these brochures for free at: http://www.jointcommission.org/speaku p.aspx Joint Commission s award-winning patient safety program Know Your Rights Understanding Your Doctors and Other Caregivers No copyright or reprinting permission required Available in English and Spanish 56
For More Information Please visit our project website: www.jointcommission.org/advancing_effective_ Communication Available: Information on new standards and Roadmap for Hospitals Hospitals, Language, and Culture study information Links to other websites and resources Christina L. Cordero, PhD, MPH ccordero@jointcommission.org 630.792.5845 57
The Joint Commission Disclaimer These slides are current as of (05/03/11). The Joint Commission reserves the right to change the content of the information, as appropriate. These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides. These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission. 58