Educating the Next CLAS: Culturally and Linguistically Appropriate Services in Today s Healthcare Environment

Educating the Next CLAS: Culturally and Linguistically Appropriate Services in Today s Healthcare Environment Christina L. Cordero, PhD, MPH Associate Project Director Department of Standards and Survey Methods Division of Healthcare Quality Evaluation The Joint Commission Opening Plenary Dallas - Fort Worth Hospital Council Foundation Arlington, Texas July 30, 2014

Educating the Next CLAS: Culturally and Linguistically Appropriate Services in Today s Healthcare Environment Time Topic 8:30 AM 9:15 AM Opening Plenary 9:30 AM 10:45 AM Panel: Governance, Leadership, and Workforce 11:00 AM 12:15 PM Panel: Communication and Language Assistance 1:30 PM 2:45 PM 3:00 PM 4:00 PM Closing Plenary Panel: Engagement, Continuous Improvement, and Accountability 2

Learning Objectives 1. Examine the importance and application of the CLAS standards 2. Identify methods to evaluate the cultural competency across leadership and of healthcare services 3. Define critical elements of and promote culturally and linguistically appropriate materials and signage 4. Develop a method to communicate progress toward implementing and sustaining CLAS standards 3

Culture and Language are Important To respond to demographic changes To eliminate health disparities To improve the quality of services and outcomes To meet legislative, regulatory, accreditation mandates To gain a competitive edge in the market To decrease the likelihood of liability/malpractice claims 5

AHRQ: Health Disparities Report 2012 National Healthcare Disparities Report AHRQ (2013) What is the status of health care disparities in the US? How have disparities changed over time? Where is the greatest need to reduce disparities? 6

Health Disparities Report Data Number and proportion of all quality measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group

Health Disparities Report Data

Factors Contributing to Disparities Patient-Level Variables - Socioeconomic status - Language barriers - Poor health literacy Health Systems-Level Variables - Organizational/financial complexity - Lack of workforce diversity Care Process-Level Variables - Provider racial or ethnic biases Institute of Medicine (2002) 9

Language Statistics In 2011, over 60 million people spoke a language other than English at home (~21% over age 5) 10

Language Statistics Approximately 25.3 million people were identified as limited English proficient (LEP) (~9% population) 11 Limited English Proficient (LEP): is defined as a patient s selfassessed ability to speak English less than very well.

Language Statistics 12

Video: Language Barriers International Medical Interpreter Association (1:42) Available free at: http://www.youtube.com/watch?feature=player_detailpage&v=twinuqacddy 13

The Joint Commission Vision Statement: All people always experience the safest, highest quality, best-value health care across all settings. Accredits/certifies over 20,000 health care organizations and programs 14

Communication and Health Care Communication is a 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 15

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 The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these root cause data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of root causes or trends in root causes over time. 16

Root Cause Sub-Categories of Communication 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) 17

The Story of Lia Lee Lia and her family Refugees from Laos Hmong culture Severe epilepsy 18 Small community hospital in California Conflict with: Treatment decisions Alternative options Medication adherence

Cultural Competence The ability of health care providers and health care organizations to understand and respond effectively to the cultural and language needs brought by the patient to the health care encounter. Cultural competence requires organizations and their personnel to do the following: (1) value diversity (2) assess themselves (3) manage the dynamics of difference (4) acquire and institutionalize cultural knowledge (5) adapt to diversity and the cultural contexts of individuals and communities served Adapted from AHRQ (2010)

Laws and Regulations Title VI of the Civil Right Act of 1964 - prohibits a recipient of funds from DHHS from discriminating against individuals on the basis of national origin (which includes primary language) Executive Order 13166 - designed to improve access to federally conducted programs and activities, who as a result of national origin, are limited in their English proficiency. Americans with Disabilities Act - No individual shall be discriminated against on the basis of disability (deaf, hard of hearing). A public accommodation shall talk steps to provide auxiliary aids and services. 20

OMH: National CLAS Standards

CLAS Standards Timeline Released in 2000 Stakeholder involvement Catalyst for other projects 14 standards Enhanced in 2013 Initiative started in 2010 Development process Public Comment Literature Review National Project Advisory Committee 15 standards 22

Enhanced CLAS Standards

CLAS Standards Themes

OMH: National CLAS Standards Principle Standard Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Create a safe and welcoming environment Ensure culturally and linguistically appropriate care Meet communication needs participate in care, make informed decisions Eliminate discrimination and disparities 25

CLAS Standards Themes Time Topic 9:30 AM 10:45 AM Panel: Governance, Leadership, and Workforce 11:00 AM 12:15 PM Panel: Communication and Language Assistance 1:30 PM 2:45 PM Panel: Engagement, Continuous Improvement, and Accountability

CLAS Standards The Blueprint 27 The Case for CLAS Enhancements Standard-by-Standard Purpose Components Implementation Strategies Resources Bibliography

What Really Happens in Hospitals? 2007 research study (n=60 hospitals) On-site visits Review policies Staff interviews Hypothetical patient Download the Report of Findings free at: http://www.jointcommission.org/advancing_ Effective_Communication 28 What challenges to hospitals face?

Hypothetical Patient Juan Lopez 60-year-old Mexican immigrant Limited English proficient 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 29

Hypothetical Patient Juan Lopez Triage nurse Emergency department physician Emergency department nurse Radiology tech Medical surgery unit for recovery 30

How would you communicate? 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. 31

How would you communicate? We use family particularly with Bosnian or Laotian [patients] where they will have smaller kids with them like maybe grade schoolers, we have to use them because [for] languages I can t identify, that is the only thing we have, so we just go with it ED Nurse Hospitals, Language, and Culture Study. The Joint Commission, 2010. 32

How would you discuss 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. 36

Hypothetical Patient Juan Lopez 60-year-old Mexican immigrant Limited English proficient 12-year-old English-speaking daughter Juanita Suffered appendicitis Cultural health belief cursed by neighbor Visits Emergency Department for temporary pain relief Plans to visit a curandera for permanent solution 34

How would you respond to his belief that his pain is from a hex? We would try as best we can to dissuade him from the belief and try to make him understand his problems are real and require some kind of medical attention. - Emergency Department Physician Hospitals, Language, and Culture Study. The Joint Commission, 2010. 35

Joint Commission Support for Effective Communication Joint Commission Accreditation Standards Existing standards Patient-centered communication standards Monograph: A Roadmap for Hospitals Example practices Resources from the field Crosswalk to CLAS Standards Comparison of CLAS and Joint Commission standards 36

CLAS-Related Standards Staff orientation on cultural diversity (HR.01.04.01, EP 5) Comply with law and regulation (LD.04.01.01) Contracted services provided safely/effectively (LD.04.03.09) Patient education meets patient needs (PC.02.03.01) Medical record contains patient language needs (RC.02.01.01, EP 1) Right to effective communication (RI.01.01.01, EP 5) Provide interpreting/translation services (RI.01.01.03, EP 2) Patient participation in care (RI.01.02.01) Informed consent (RI.01.03.01) 37

Patient-Centered Communication Standards Qualifications for language interpreters/translators (HR.01.02.01, EP 1) Identify communication needs (PC.02.01.21, EP 1) Address communication needs (PC.02.01.21, EP 2) Provide language services (RI.01.01.03, EP 2) Collect preferred language data (RC.02.01.01, EP 1) Collect race and ethnicity data (RC.02.01.01, EP 28) Allow patients access to a support individual (RI.01.01.01, EP 28) Ensure care free from discrimination (RI.01.01.01, EP 29) 38

40 Questions?

The Joint Commission Disclaimer I have no personal financial relationships with commercial interests relevant to this presentation By matter of policy, The Joint Commission does not endorse any company or product. These slides are current as of (06/30/14). 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. 41