1. 1 1 Nuts and Bolts of Collecting Patient Race, Ethnicity and Language Data Staff Training [Your hospital name] [Date]

2. 2 Purpose of Training We are implementing a standardized method of collecting race, ethnicity and language (R/E/L) data as self-reported by patients or their caregivers. You are key to ensuring all data are collected consistently, accurately, professionally, and completely.

3. 3 Learning Objectives After this training session you will be able to: – Describe the reasons for standardizing the collection of patient R/E/L – Understand the importance of using scripts to ask each patient to self-identify his/her R/E/L – Address patient questions and concerns

4. 4 What are disparities in health care quality? Racial or ethnic disparities are differences in the quality of health care received by members of different racial or ethnic groups that are not explained by other factors - National Healthcare Disparities Report, 2008, AHRQ

5. 5 Why collect standardized R/E/L data? To plan quality improvement initiatives To better understand patient demographics To ensure adequate interpreter services, patient information materials, and cultural competency training for staff To link patient race, ethnicity and language data with clinical information To identify and eliminate any health care disparities To ensure that all patients receive high-quality care

6. 6 Health Care Reform: – ARRA (2009): Creates the HIT Policy Committee to make recommendations on development of electronic data collections methods for R/E/L. – Patient Protection and Affordable Care Act (2010): Requires all federal health programs and surveys to collect R/E/L; requires HHS Secretary to analyze and use the data to monitor trends in disparities; establishes a national strategy to improve delivery of care, patient outcomes and disparities reduction. Joint Commission: New and revised standards address: Qualifications for interpreters; identifying and addressing communication needs; collecting language data, and the provision of language services. Title VI of the Civil Rights Act of 1964: Requires that federal aid recipients provide oral and written language assistance to LEP persons. Why collect standardized R/E/L data?

7. 7 What is standardized data collection? Standardized categories are used across the hospital/system Telling the patient why we are asking for his/her R/E/L Patient self-reports R/E/L –No more “eyeballing” the patient –Data is collected from all patients

8. 8 Why are we making this change at [hospital name] ? [Add text] Examples: “[Hospital name] is committed to providing safe, timely, efficient, equitable, and patient-centered care. Because non-whites comprise [ x %] of our population, equity and quality demand attention.” “We believe that the best way to eliminate racial disparities and to elevate the overall quality of care for all is to create processes of care to systematically treat all patients equitably.” Provide the reason(s) that explain to staff why your hospital will be collecting standardized patient self-reported race, ethnicity and language data. Insert your hospital name here

9. 9 “….but we already collect this information!” That may be true, but results of a national study that examined R/E/L data collection in hospitals showed: – Even if hospitals are collecting the data, not everyone is doing a good job. We need uniform categories. – Many registrars collect the information by observing the patient and guessing. We must allow the patient to self- identify. Applies to all patient care registration settings.

10. 10 Impact on Registration/Admitting Staff The collection of standardized race, ethnicity and language information from all patients will affect: – Staff training/ evaluation – Registration system and processes – Communication with patients – How data are used to monitor quality

11. 11 What do we mean by race, ethnicity and language?

12. 12 Minimum race, ethnicity and language categories Race Black White Asian American Indian/Alaska Native Native Hawaiian /Pacific Islander Multiracial* Declined* Unavailable* Spoken and Written Language English Spanish Other Declined * Unavailable * *This designation indicates a modification to the OMB R/E categories Ethnicity Hispanic Not Hispanic Declined* Unavailable* Improving Language Services will also collect: American Sign Language French Russian Somali

13. 13 Challenging assumptions – what is her/his race?

14. 14 Race definitions Black or African American: Person having origins in any of the black racial groups of Africa. White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Asian: Person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. American Indian or Alaska Native: Person having origins in any of the original peoples of North and South America (including Central America) and maintains tribal affiliation. Native Hawaiian or Other Pacific Islander: Person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Multiracial*: A person having more than one or a combination of the above origins. Declined*: Patient is unwilling to choose a race category or cannot identify him/herself with one of the listed races. Unavailable*: Patient is physically unable to respond. *This designation indicates a modification to the OMB R/E categories Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009http://www.hretdisparities.org/

15. 15 Ethnicity definitions Hispanic or Latino: Person of Cuban, Mexican, Puerto Rican, South or Central American decent, regardless of race. Non-Hispanic or Latino: Person not of Hispanic or Latino ethnicity. Declined*: Patient is unwilling to provide an answer to the ethnicity question or cannot identify him/herself as Hispanic or Not Hispanic. Unavailable*: Patient is physically unable to respond. *This designation indicates a modification to the OMB R/E categories Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009http://www.hretdisparities.org/

16. 16 Challenging assumptions – what is his ethnicity?

17. 17 Spoken and Written Language definitions English: English is the language identified by the patient for speaking to health care providers or reading health care information. Spanish: Spanish is the language identified by the patient for speaking to health care providers or reading health care information. Other: Any stated language other than English or Spanish. Declined: A person who is unwilling to state a language preference. Unavailable: Patient is physically unable to respond.

18. 18 Locally Relevant List for Ethnicity Spaniard Andalusian Asturian Catalonian Belearic Islander Gallego Valencian Canarian Spanish Basque Mexican Mexican American Mexicano Chicano Puerto Rican Cuban

19. 19 What [new] questions will you be asking?

20. 20 Recommended script for patient’s ethnicity “First, do you consider yourself Hispanic or Latino?”  Yes  No  Declined  Unavailable Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009http://www.hretdisparities.org/ If your hospital is going to use a different question, you can use that text on this slide.

21. 21 Ethnicity screen Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009http://www.hretdisparities.org/ If applicable, you can include a screen shot that shows registration staff any changes to their computer screen. Example

22. 22 Recommended script for patient’s race “Which category best describes your race?”  Black/African American  White  Asian  American Indian/Alaska Native  Native Hawaiian/Other Pacific Islander  Multiracial  Declined  Unavailable Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009http://www.hretdisparities.org/ If your hospital is going to use a different question, you can use that text on this slide.

23. 23 It is PREFERRED, not primary language Definition: “the language that is stated by the patient for speaking with health care providers or for reading health care information.” Office of Civil Rights (OCR): “the language that an LEP individual identifies as the one he/she uses to communicate effectively and would prefer to use to communicates with service providers.” National Quality Forum Cultural Competency Framework (2009): “the self selected language the patient wishes to use to communicate with his/her health care provider. HRET Toolkit: “What is your preferred spoken language?” Roat (2005): “In what language do you prefer to receive your health care?” The Joint Commission: New standards for provide patient communication specifies preferred language.

24. 24 Recommended scripts for patient’s preferred language Spoken language: “What language do you feel most comfortable speaking with your doctor or nurse?” Written language: “What language do you feel most comfortable reading medical or health care instructions?” Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009http://www.hretdisparities.org/ If your hospital is going to use a different question, you can use that text on this slide.

25. 25

26. 26 What tools are available to help us collect R/E/L data from patients?

27. 27 Recommended script “We want to make sure that all our patients get the best care possible. We would like you to tell us your racial/ethnic background and preferred language so that we can review the treatment that all patients receive and make sure that everyone gets the highest quality care.” Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009http://www.hretdisparities.org/ If your hospital is going to use a different script, you can use that text on this slide.

28. 28 OUR COMMITMENT TO YOU Please select which of the following best describes your race:  American Indian/ Alaskan Native  Asian  Black or African American  Native Hawaiian/ Other Pacific Islander  White  Choose Not the Answer Please select which category best describes your ethnicity:  Hispanic/ Latino  Not Hispanic/ Latino  Choose Not the Answer

29. 29 “I Speak” Poster Source: Cambridge Health Alliance (Cambridge, MA)

30. 30 “I Speak” Card

31. 31 How will we let our patients know?

32. 32 We Are Asking New Questions

33. 33 Excerpt from registration materials We are now collecting race, ethnicity and perferred language information from all of our patients to help us know them better. We can learn more about the communities we serve if we know your race and ethnicity. We can meet the needs of all patients if we know more about race, ethnicity, language and culture. Source: Cambridge Health Alliance (Cambridge, MA)

34. 34 We Ask Because We Care Wall Posters Can be displayed in: Registration areas Waiting rooms

35. 35 How will staff concerns be addressed?

36. 36 What do staff think? “It will take too much time to ask these questions” “Patients will get angry if we ask these questions” “It’s illegal to collect this information” “We don’t need to collect this information, we already know who our patients are” “I’m uncomfortable asking these questions”

37. 37 Addressing Staff Concerns Most patients (80%) think hospitals should be collecting data. Most patients (97%) also think it’s important for hospitals to examine differences in quality. Some patients are concerned about how the data will be used. Study conducted at Northwestern Memorial Hospital. Baker et al. 2005, JGIM.

38. 38 Addressing staff concerns Possibilities include: – We will conduct training sessions, role-playing exercises and focus groups where you can ask questions – We will provide tools and resources to help you – We will ask for feedback on how the process is going – We will provide guidance for solving problems as needed Use this slide to describe the ways your hospital will continue to address the concerns of the registration staff.

39. 39 Addressing patient concerns: Response matrix Source: HRET Toolkit, http://www.hretdisparities.org/ accessed on Sept 16, 2009http://www.hretdisparities.org/ Patient ResponseSuggested Response “I'm American." Would you like to use an additional term, or would you like me to just put American? "Can't you tell by looking at me?" Well, usually I can. But sometimes I'm wrong, so we think it is better to let people tell us. I don’t want to put in the wrong answer. I’m trained not to make any assumptions. "Who looks at this?" The only people who see this information are registration staff, administrators for the hospital, and the people involved in quality improvement. "I'm human." Is that your way of saying that you don’t want to answer the question? If so, I can just say that you didn't want to answer. "I was born in Nigeria, but I've really lived here all my life. What should I say?" That is really up to you. You can use any term you like. It is fine to say that you are Nigerian.

40. 40 Resources and Tools Scripts for collecting R/E/L Patient Response Matrix “I Speak” Posters “We Ask” Posters and Tent Cards R/E/L category definitions Optional granular ethnicity and language categories