1. 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 Patient Safety Analyst The Johns Hopkins Hospital

2. Objectives This presentation will provide an overview of: – The effects of language barriers on patient safety and quality of health care – Addressing the needs of LEP and HI effectively – The importance of non-English materials, access to language services, and the use of universal symbols in health care environments – Experiences, lessons learned, and success stories from Johns Hopkins Hospital and other organizations

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4. 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 limited English proficient (LEP) and hearing impaired (HI) patients

5. Scope of the Problem: U.S. Demographics Almost 35 million U.S. residents are foreign born. Almost 47 million people (18% of the U.S. population) speak a language other than English at home. 11 million to 21 million people (4.2% to 8.1% of the U.S. population) speak English less than "very well" and are considered LEP. Approximately 20 million people (8.6% of the population 3 years and older) are reported to have hearing problems.

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7. 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.

8. Federal Mandates and Regulations However, neither of these mandates includes funding and the burden of the cost of language services remains the responsibility of the provider. – For example, an American Medical Association (AMA) survey found that the cost of interpreter services ranged from $30 to $400 an hour, while the average Medicaid office visit reimbursement was only $30 to $50. – Private payers also do not reimburse for interpreter services.

9. Federal Mandates and Legislation The lack of availability of qualified, medical interpreters and inadequate funding are two major impediments to providing language services.

10. 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.

11. 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.

12. Patient Safety and Healthcare Quality One study analyzed 1,083 adverse incident reports from six Joint Commission-accredited hospitals for English speaking and 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.

13. Patient Safety and Healthcare Quality In the past, health care providers have resorted to drastic measures in an effort to provide language services. 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.

14. 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. In many instances, a family member serves as an interpreter, which raises privacy and other concerns. – For example, California Assemblyman Leland Yee remembers translating for his mother at the doctor's office when he was only six years old.

15. Patient Safety and Healthcare Quality Several states have introduced legislation forbidding children under sixteen from serving as interpreters.

16. Patient Safety and Healthcare Quality Untrained interpreters are more likely to commit errors in interpretation that can lead to adverse clinical consequences. In addition, they do not have the requisite 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.

17. Patient Safety and Healthcare Quality Occasionally, a bilingual health care 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--"I hit her" instead of "She hit herself."

18. Patient Safety and Healthcare Quality In the absence of any language service (trained or untrained), care can be compromised or delayed. – For example, a hearing impaired patient presented for surgery. – Although a sign-language interpreter had been requested, none was available. – The health care team communicated by passing written notes back and forth. – Although this was less than optimal, the patient ended up being only ten minutes late for the procedure.

19. Patient Safety and Healthcare Quality In other instances, the results can be catastrophic. – 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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21. Discussion What issues arose during this scenario?

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23. Discussion How was this scenario improved with the assistance of a trained, staff interpreter?

24. Best Practices: The Johns Hopkins Hospital Per the 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 5-2273.

25. Best Practices: The Johns Hopkins Hospital

27. The Emergency Department is piloting the use of a robot for Spanish-language interpretation.

28. Best Practices: The Johns Hopkins Hospital Johns Hopkins International has translated certain patient education materials into various foreign languages.

29. Best Practices: The Johns Hopkins Hospital

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

31. Best Practices: The Johns Hopkins Hospital

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

33. Resources Limited English Proficiency: A Federal Interagency Website http://www.lep.gov/resources/resources.html http://www.lep.gov/resources/resources.html Hablamos Juntos: Language Policy and Practice in Health Care http://www.hablamosjuntos.org/ http://www.hablamosjuntos.org/ – See: Universal Symbols in Health Care Workbook http://www.hablamosjuntos.org/signage/PDF/Best %20Practices-FINALDec05.pdf

34. Resources Diversity Rx http://www.diversityrx.org/ http://www.diversityrx.org/ A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations http://www.omhrc.gov/Assets/pdf/Checked/HC- LSIG.pdf http://www.omhrc.gov/Assets/pdf/Checked/HC- LSIG.pdf Joint Commission: Hospitals, Language, and Culture http://www.jointcommission.org/PatientSafety/HLC/

35. Resources Oral, Linguistic, and Culturally Competent Services: Guides for Managed Care Plans http://www.ahrq.gov/about/cods/cultcomp.ht m http://www.ahrq.gov/about/cods/cultcomp.ht m Providing Oral Linguistic Services: A Guide for Managed Care Plans http://www.ahrq.gov/about/cods/oralling.htm

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37. Resources To order the video, Breaking Down the Language Barrier: Translating Limited English Proficiency into Practice – Contact the Department of Justice at: crt.lep@usdoj.gov or Sharon Williams at: Sharon.V.Williams@usdoj.gov crt.lep@usdoj.gov – CDs and associated materials are available for free

38. Questions ???

39. For additional information, contact: Cheri Wilson, cwilso42@jhmi.edu