One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations Amy Wilson-Stronks, MPP, CPHQ Principal Investigator Hospitals, Language, and Culture study Division of Standards and Survey Methods The Joint Commission 2008 MIAB Conference The $ and Sense of Culturally Effective Care:  Access, Communication, and Commitment October 31, 2008

Today’s Journey Through the Eyes of a Patient – Meet Juan Lopez 60-year-old Mexican immigrant Doesn’t speak English Limited experience with the U.S. health care system 12-year-old English-speaking daughter Juanita

Our Story Begins… Juan Lopez presents to Hospital X’s Emergency Department, accompanied by his daughter Juanita. He is writing in pain and clutching his stomach. He declares to the triage nurse, “!Mi vecino me puso una brujeria!”

Who Juan Lopez Encounters: Triage nurse Emergency department physician Emergency department nurse Radiology tech Medical surgery unit for recovery

Ideally, how would staff communicate with Juan Lopez at your organization?

Ideally, how would staff respond to the hex at your organization?

Communication is the Cornerstone of Patient Safety

The Need for Accurate Information Assess patient needs Determine diagnosis/prognosis Provide Treatment Obtain consent Educate/Inform Hand-off communications

Multiple Players in Communication Patient/family Physicians Nursing Pharmacy Physical Therapists Speech Therapists Occupational Therapists Social Workers Psychologists Lab Imaging Billing

Factors That Can Inhibit Communication Abilities Hearing impairment Visual impairment Cognitive Limitation Intubation Disease (ALS, Stroke) Health Proxy Culture Literacy Language

Poor Communication Impacts Patient Safety Communication vulnerable patients are at increased risk for: Serious medical events (Cohen et al., 2005) Sentinel events (The Joint Commission, 2007) Poor medication compliance/ adherence (Andrulis et al., 2002; Flores et al., 2003)

Root Causes of Sentinel Events 12

Hospitals, Language, and Culture: A Snapshot of the Nation (HLC) Cross-sectional qualitative study Three Research Questions: What are the challenges hospitals face providing care to diverse patient populations? What are hospitals doing to address these challenges? Are there any promising practices that can be replicated to improve care?

HLC Sample Hospitals (n=60) Region (representing 32 states) West 21 Midwest 12 South 17 Northeast 10 100-299 beds: 18 Rural: 15 25-99 beds: 10 Non-profit:32 300+ beds: 32 Urban: 35 Public: 15 Teaching/Academic: 22

HLC Study Methodology Cross-sectional qualitative study of 60 hospitals 2 samples of 30 hospitals In-person administrative interviews CEO (one-on-one) Leadership, Human Resources, Cultural and Language Services (3 groups of 3 representatives) In-person clinical interviews Patient-centered assessment interviews focused on a clinical case scenario (one-on-one) Source: Hospitals, Language, and Culture Study, A.Wilson-Stronks et.al, 2008 15

Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings Wide range of practices/interpretation of good practice Gap between current practice and desired practice Missing resources Resources, processes not being used Culture and language are challenging issues to address Download the report free: http://www.jointcommission.org/ patientsafety/hlc

Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings More focused efforts on language than culture Data collection and use is inconsistent across and within hospitals Need for greater clarity in Joint Commission standards regarding effective communication Download the report free: http://www.jointcommission.org/ patientsafety/hlc

Leadership Support: A Key to Success Insights from Hospital CEOs

Recommendations: The Role of Leadership Establish a centralized program to coordinate culture and language services Make the commitment to culturally and linguistically appropriate care highly visible Have internal multidisciplinary dialogues Research is needed to better understand what drives hospital CEOs who embrace culturally and linguistically appropriate care Source: Wilson-Stronks A, Galvez E. Exploring cultural and linguistic services in the nation’s hospitals: A report of findings. Oakbrook Terrace, IL: The Joint Commission; 2007. 

Recommendations: Collecting and Using Data Implement a uniform framework for the collection of data on race, ethnicity, and language. Stratify service and technical quality measures such as those reported through the Hospital Quality Alliance, by language, race, and ethnicity Source: Wilson-Stronks A, Galvez E. Exploring cultural and linguistic services in the nation’s hospitals: A report of findings. Oakbrook Terrace, IL: The Joint Commission; 2007. 

Recommendations: Provision of Language Services & Workforce Establish and implement written policies that do not permit the use of family members/ad hoc individuals to interpret Assess English and target language proficiency of all individuals used to interpret Incorporate language service programs into safety and quality efforts - PI structures and tools Provide ongoing training on how and when to access language services Source: Wilson-Stronks A, Galvez E. Exploring cultural and linguistic services in the nation’s hospitals: A report of findings. Oakbrook Terrace, IL: The Joint Commission; 2007. 

Recommendations: Provision of Care & Community Engagement Formalize processes for translating written materials (patient rights, informed consent, etc.) Use health care interpreters and cultural brokers to facilitate communication Take advantage of internal and external resources available to learn about cultural beliefs Make staff aware of the tendency toward stereotyping to avoid assumptions about patients Make use of community resources through networks, collaborations, and partnerships Source: Wilson-Stronks A, Galvez E. Exploring cultural and linguistic services in the nation’s hospitals: A report of findings. Oakbrook Terrace, IL: The Joint Commission; 2007. 

How Can the Findings Be Used? The recommendations recognize that an integrated effort among hospitals, policymakers, and researchers is required. Can use findings as benchmark and use recommendations to conduct gap analysis.

Hospitals, Language, and Culture: A Snapshot of the Nation Cross-sectional qualitative study Three Research Questions: What are the challenges hospitals face providing care to diverse patient populations? What are hospitals doing to address these challenges? Are there any promising practices that can be replicated to improve care? 24

One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations Released April 21, 2008 Download a free copy of the report on HLC website Thematic framework derived from current practices in 60 hospitals Download this report free at: http://www.jointcommission.org/patientsafety/hlc 25

Theme 1 - Building a Foundation Developing a supportive infrastructure for cultural competence Cultural competence in organizational planning Developing policies for cultural competence Integrating culture and language (C&L) into organizational systems Recruiting and sustaining a diverse workforce Creating a high-level task force Structuring budget systems for culturally and linguistically appropriate care Integrating cultural competence into patient care Providing appropriate language services Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 26

Theme 1 - Building a Foundation “It’s one thing to put it in a mission and vision statement and plaster it on the wall and to say we serve all people in the community regardless of ethnicity or race; it’s another thing to actually do it.” –CEO from a northeastern hospital “I think the biggest challenge is making certain that staff and employees [practice] cultural sensitivity. This is a people business and as much as the CEO might issue an edict…[cultural sensitivity] does not happen unless you invest in your employees.” –CEO from a western hospital Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 27

Theme 2 - Collecting and Using Data to Improve Services Assessing the need for C&L services Collecting community- and patient-level data Monitoring C&L service utilization Collecting data on service use Building upon C&L service utilization data Using data to improve C&L services Establishing a baseline of services Obtaining patient feedback Stratifying data by demographic variables Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 28

Theme 2 - Collecting and Using Data to Improve Services “Collection of data is critical. Data shows you who your population[s] [are] and what languages these populations speak. Further [scrutiny] of the data allows the facility to see what services they are most apt to seek…. Data allows [human resources] to conduct an annual comparison of employee mix to community and patient load. If the patient data does not proportionately match the community data, then the facility must ask if there is a reason why that population is not accessing services.” –HLC Technical Advisory Panel member Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 29

Theme 3 - Accommodating the Needs of Specific Populations Staff awareness through training, dialogue, and support Training on effective communication, cultural competence Providing staff with educational resources Creating an environment that meets specific needs Enhancing the hospital’s physical space Adapting services to address cultural beliefs Helping patients manage their care Navigating the health care system Providing patient education Establishing centralized programs that meet specific needs of large populations Culturally and religious/spiritually centered Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 30

Theme 3 - Accommodating the Needs of Specific Populations “[The doula program] came out of dialogue with women from the community that we were able to bring in [to] talk about their birth practices [and] our birth practices…. We literally sent vans out to go pick women up and bring them here to have a dialogue. It was as informal as that. It [developed] into the doula program that we [now] have.” –A member of C&L services from a midwestern hospital Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 31

Theme 4 - Establishing Internal and External Collaborations Working together within the hospital Establishing a cultural diversity committee Bringing diverse stakeholders together Building bridges with other hospitals Sharing, pooling existing resources Engaging the community Community partnerships to create a diverse workforce Using community leaders to bridge cultural barriers Becoming an active member of the community Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 32

Theme 4 - Establishing Internal and External Collaborations “We are part of a local collaborative, where six or seven different health care systems have come together and said, ‘We don’t all need to translate all of our diabetic and education information into these six or seven languages. Why don’t you take on doing half of those, and we’ll do half of those, and let’s take our letterhead off of that information.’ We can use that information across the system.” –A member of C&L services from a midwestern hospital Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 33

Supporting References for Practices Hospitals, Language, and Culture: A Snapshot of the Nation’s Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings American Medical Association, Ethical Force Program’s Improving Communication—Improving Care: How Health Care Organization Can Ensure Effective, Patient-Centered Communication with People from Diverse Populations Office of Minority Health’s National Standards for Culturally and Linguistically Appropriate Services in Health Care The Joint Commission’s “What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety 34

The Big Question: How can the practices in this report help my organization better serve our diverse patients??

Chapter 8: Tailoring Initiatives to Meet the Needs of Diverse Populations There is no “one size fits all” solution for cultural competence. Each organization is unique. Organizations need to: Identify the needs of the population served Assess how well needs are met through current systems Bring people together to explore C&L issues Make assessment, monitoring, and evaluation of needs and services a continuous process Implement a range of practices spanning all 4 themes of this report in a systemic manner Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 36

Methods for Self-Assessment Focus groups In-services Lunch meetings Seminar series Small-group interviews Staff retreat Targeted interviews Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 37

Potential Participants Chief executive, medical, nursing, operating officers Community members Dietary services Diversity officer Financial assistance/ billing staff Hospital chaplain Human resources director Information technology staff Intake staff Language services coordinator Medical and nursing staff Patient advocates Patient safety officer Patients and families Quality improvement officer Recruiter Risk management officer Social services Staff/clinical educator Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 38

from Self-Assessment Tool Sample Questions from Self-Assessment Tool Building a Foundation How does our leadership currently support the provision of culturally competence care? Collecting and Using Data to Improve Services How have we assessed the C&L needs of the community? Our patients? Accommodating the Needs of Specific Populations What aspects of the physical environment have been evaluated to determine whether they meet specific patient needs? Establishing Internal and External Collaborations What community organizations or networks, religious leaders or chaplains, or traditional healers can we collaborate with to meet patient needs? Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 39

Field Test of the Self-Assessment Tool 2-hour workshop with an organization’s cultural diversity committee Questions from Theme 1 – Building a Foundation 3 facilitated small group sessions Large group discussion of responses Received positive feedback (n=25) Participants indicated it was a useful exercise The tool helped people learn more about their organization Overall the questions were understandable 40

We want your feedback! Evaluation form available as an electronic survey on HLC website; paper copies in published reports Organizations are encouraged to provide feedback after using the self-assessment tool: How did your organization use the tool? Who was involved? How useful do you feel the tool is? What type of organization are you from? Where is your organization located? Additional comments and suggestions for improvement Survey available at: http://www.jointcommission.org/patientsafety/hlc 41

Summary – One Size Does Not Fit All Thematic framework derived from current practices in 60 hospitals Self-assessment tool to tailor initiatives to meet the needs of diverse patient populations Cultural competence is an ongoing journey - hospitals should assess and re-assess the services they provide Download this report free at: http://www.jointcommission.org/patientsafety/hlc 42

Evolution of Joint Commission Standards Supporting CLAS Identification of certain rights for all patients Increased patient awareness related to patients’ participation in care Cultural competence is more than a patients’ rights issue; it is critical to safety and quality of care

Developing Hospital Standards for Culturally Competent Patient-Centered Care 18-month standards development project (August 2008 through January 2010) Project will explore how diversity, culture, language, and health literacy issues can be better incorporated into current Joint Commission standards or drafted into new requirements  Standards will build upon previous studies and projects, including the research framework from the HLC study and evidence from the current literature.

Developing Hospital Standards for Culturally Competent Patient-Centered Care A multidisciplinary Expert Advisory Panel will provide guidance regarding principles, measures, structures, and processes that will be the basis of standards Collaboration with National Health Law Program (NHeLP) to develop an implementation guide to prepare organizations for new standards

For More Information Hospitals, Language, and Culture study website: www.jointcommission.org/patientsafety/hlc/ Available: Downloadable reports HLC study information Links to other websites Resources Amy Wilson-Stronks awilson-stronks@jointcommission.org