1. Meeting Joint Commission Standards for Health Literacy
Christina L. Cordero, PhD, MPH
Project Manager
Division of Standards and Survey Methods
The Joint Commission
Wisconsin Literacy
SW/SC Regional Health Literacy Conference
October 15, 2008

2. Communication and Health Care
Communication is the cornerstone of patient safety
Health care is communication-dependent
Accurate information is needed for:
Assessment
Diagnosis
Treatment
Consent
Education

3. Multiple Players in Communication
Patient/family
Physicians
Nursing
Pharmacy
Physical Therapy
Speech Therapy
Occupational Therapy
Social work
Psychology
Lab
Imaging
Billing
Communication is complicated
It involved many different people
Effective communication is difficult to operationalize - there is no easy answer to what is effective
When we talk about communication, we’re talking about communication throughout the continuum of care
This includes any health care that patient receive (mental health, physical therapy)
Services (social work)
And administration (billing)

4. Communication-Vulnerable Patients
Access to direct communication can be inhibited by:
Language
Culture
Hearing or visual impairment
Health Literacy
Cognitive Limitation
Intubation
Disease (ALS, Stroke)
Communication-vulnerable patients are at increased risk for serious medical events

5. Functional Health Literacy
Ability to read, understand, and act on health information
Half the adult U.S. population lacks the skills to function within the healthcare system (IOM)
90 million Americans do not understand what they are told by their providers (AMA)
Everyday application of the four components:
Reading
Writing
Math
Oral Language
Hearing & Speaking
When we are talking about health literacy, we are referring to functional health literacy
According to the IOM, half the adult U.S. population lacks the skills to function within the healthcare system
The core components which are:
Reading
Writing
Math
Oral Language skills – both hearing and speaking
As we refer to functional literacy, we need to remember that it requires skills in each of these areas

6. Implications of Low Functional Literacy
How patients navigate the healthcare environment system
What patients know and understand about medicine and human biology
How they communicate with providers
How well they can serve as an advocate for their own care
Low functional health literacy has implications throughout the continuum of care including:
Patient’s ability to navigate the health environment
Where do they present?
Who are they supposed to contact?
How do you get through the procedures? (Can they complete the forms? Did they bring everything they were supposed to?)
Is there a process in place for guiding patients through these processes?
Communication with providers (again, talking about all of the services they come in contact with)
How are patients being asked to provide information?
How is information being communicated to patients?
Is there any process or indication that there is mutual understanding
Patients’ understanding about human biology and medicine
Do they understand the terms that are being used?
Do they understand the underlying processes that are explained in descriptions of diagnosis, testing, screening, etc.?
Conditions - what is high blood pressure?
Patients’ ability to advocate for their own care
Do they feel comfortable asking questions?
Do they know what questions to ask?
Do they understand the instructions they were given?

7. Health Literacy and Patient Care
Environment/Structure
Navigational tools
Do signs need to be in multiple languages?
Are there colors/symbol systems that could be used?
What information is provided to patients before their visit?
Communication formats
Do chosen formats – written, online, verbal - present added challenges or demands on patients?
Since health literacy impacts all levels of patient care, organizations need to look at communication throughout these levels and the continuum of care:
Environment/structure
How easily can patients find their way around?
What information/instructions (if any) are they given before arriving?
How is information provided?
What assumptions are being made? (x-ray vs. radiology)
Is the organization communicating with patients that requires additional skills?
For example, providing information online may be highly innovative, but does it place additional demands or make assumptions about the audience – would they know how to search for something? Would they know how to navigate the website to find what they need)
How can these systems processes be more patient-friendly?

8. Health Literacy and Patient Care
Written Materials
Forms, consents, instructions, educational materials, medication labels, etc.
What is the readability (reading level, flow, etc.)?
What languages are materials provided in (how have they been translated)?
How complicated are any diagrams, charts, or tables?
Is written information the optimal format for providing this type of information? Are there alternatives feasible?
What information is provided in writing?
How is this information organized?
Are there certain assumptions or skills the materials required to understand the information? (complex or embedded tables, multi-layered bulltets)
White space or is it text-heavy?
What is the readability? (it’s not just about the formula – do not sacrifice grammar)
How complex is the information?
Does it make assumptions about knowledge/understanding? (computer/telephone access, skills)
What type of jargon is being used? E.g. provider, caretaker
What languages are materials provided in?
Have these been translated by professional translators (vs. online translation software)
Are there alternative ways of conveying this information that would make it more patient-friendly?

9. Health Literacy and Patient Care
Verbal Communication
What communication barriers might there be?
Is there too much jargon being used?
Is verbal information being supplemented in any way?
What resources are available to bridge barriers?
What might impede patient-provider communication?
language (LEP – next slide), health literacy, culture, intubation,
Is information being conveyed in ways that can be understood?
How much jargon is being used?
Is this information supplemented?
Are there additional resources?
How is understanding being assessed?
nodding, asked questions or not asked questions, repeat back
power dynamic

10. Limited English Proficiency (LEP)
A legal concept referring to a level of English proficiency that is insufficient to ensure equal access to public services without an interpreter; the inability to speak, read, write, or understand English at a level that permits an individual to interact effectively with health care providers or social service entities (DHHS)
LEP patients have varying degrees of literacy
Despite limited abilities in English, LEP patients may have high-level abilities in their native language
In terms of health, there are cultural considerations also
Double burden
Risk for low health literacy
Don’t speak the language – difficult to communicate even basic information
United States Department of Health and Human Services, Office for Civil Rights. Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. Washington, DC: HHS;2003:68 Fed. Reg. At

11. Activities Dependent Upon Effective Communication
P r e v e n t i o n & H e a l t h P r o m o t i o n
P o s t – D i s c h a r g e C o m p l i a n c e
Factors Influencing
Effective Communication
M e d i c a t i o n M a n a g e m e n t
D i s c h a r g e I n s t r u c t i o n
T r e a t m e n t P l a n n i n g
Language
I n f o r m e d C o n s e n t
Culture
D i a g n o s i s
H a n d – o f f s
E d u c a t i o n
Health Literacy
Illness
Disability
Cognitive Impairment

12. Implications for Patient Safety
People with low health literacy are less likely to use screening and prevention services, understand how to take their medications, keep chronic health conditions in check, and more likely to be hospitalized (AHRQ)
Health literacy has implications for patient safety, for example
Low health literacy is correlated to lower utilization of screening/prevention
Poorer understanding of medications
Poorer self-management of chronic disease
Increase hospitalization

13. Communication Barriers and Patient Safety
COMMUNICATION FACTORS
COMMUNICATION PROBLEMS
INTERPRETER
PATIENT
PROVIDER
PROVIDER ORGANIZATION
EXPRESSION
ADVERSE EVENT
COMPREHENSION

14. Communication and Sentinel Events
Impact of communication on sentinel events
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.

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 since July 2006
Communication identified as a root cause for 533 Sentinel Events reported to The Joint Commission

16. Root Cause Sub-Category Root Cause Additional Detail Occurrences
Among Staff - 354
Communication of Relevant Patient Information
277
Communication Between Units of the Organization
114
Communication with Other Provider Organizations 27
Other 24
With Physician - 226
Between Staff and Attending
167
Between Physicians 55 17
Between ER Physician & Attendings 14
Timely request for consultation 8
Oral Communication - 54
Other oral communication problem
Incomplete change-of-shift report 19 7
Verbal Orders 1
With Patient or Family - 54 54
Written Communication - 40
Other Written Communication Problems 32
Transcript Error/Availability 5 4
With Administration - 21
Delayed Report of Hazardous Conditions 16
Electronic Communication - 9
Other Electronic Communication Problems
Paging System Problem
Fax System Problem

17. Joint Commission Support for Effective Communication
Joint Commission Accreditation Standards
Public Policy White Paper: “What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety
Research Study: Hospitals, Language, and Culture: A Snapshot of the Nation
Standards Development Project: Developing Hospital Standards for Culturally Competent Patient-Centered Care
Speak Up materials:
Know Your Rights
Understanding Your Doctors and Other Caregivers

18. Ethics, Rights, & Responsibilities
Standard RI.2.100: The hospital respects the patient’s right to and need for effective communication.
EP 1: The hospital respects the right and need of patients for effective communication.
EP 2: Written information provided is appropriate to the age, understanding, and as appropriate, to the population served, the language of the patient.
EP 3: The hospital provides interpretation (including translation) services as necessary.
EP 4: The hospital addresses the needs of those with vision, speech, hearing, language and cognitive impairments.
Definitions new for 2008
Interpretation services: provide for the communication needs of patients who have limited English proficiency or are deaf/hard of hearing. An interpreter is a person who renders a message spoken or signed in one language into one or more languages. Interpretation works only with spoken/signed language.
Translation services: provide translation of written documents into other languages. A translator is a person who converts the written text of one language into the written text of one or more languages. Translation works only with written text.
EP 2: understanding includes health literacy
EP 3:
When we talk about translated documents we have to consider issues of language, health literacy, and culture
Is the translation accurate?
Does the translation take any cultural issues into consideration?
What is the readability in the target language? Documents that are poorly written in English are not more understandable in another language.
National Health Law Program (NHeLP) just released Summary of State Law Requirements Addressing Language Needs in Health Care
NY Complication of Codes, Rules, and Regulations
Under patients’ rights, hospitals must provide skilled interpreters and translations of all significant forms to ensure effective communication with all persons receiving treatment regardless of language.
Hospitals must designate a Language Assistance Coordinator and develop a Language Assistance Program.
Interpreters and translations shall be regularly available for non-English speaking groups comprising more than one percent of a hospital’s service area.
Interpreters must be available in inpatient and outpatient settings within 20 minutes and in emergency rooms within 10 minutes of a request by the patient, the patient’s family or representative, or a health care provider.

19. Ethics, Rights, & Responsibilities
Standard RI.2.20: Patients receive information about their rights.
EP 1: Information on rights is provided to each patient.
Standard RI.2.30: Patients are involved in decisions about their care, treatment, and services provided.
EP 1: Patients are involved in decisions about their care, treatment, and services.
EP 2: Patients are involved in resolving dilemmas about care, treatment, and services.
When we talk about receiving information about rights, how is that operationalized?
Are patients signing a form that confirms they received the information?
How is information being provided
In writing?
In pamphlet? On a poster in the waiting room? Online?
In what languages?
What is readability?
How is the information laid out?
Does it make certain assumptions?
Do providers engage in dialogues about the information?
We once again have to think about assessing understanding
In order to be involved in decisions about care, treatment, services

20. Ethics, Rights, & Responsibilities
Standard RI.2.40: Informed consent is obtained.
EP 3: A complete informed consent process includes a discussion of the following elements:
Nature of the proposed care, treatment, services, medications, interventions, or procedures
Potential benefits, risks, side effects
Likelihood of achieving goals
Reasonable alternatives
Relevant risks, benefits, side effects related to alternatives
Limitations on the confidentiality of information
Informed consent
Process rather than form
What do patients need to know to make an informed decision about their care?
Complicated information
How is that information being communicated?
How is understanding being assessed?

21. Information Management
Standard IM.6.20: Records contain patient-specific information, as appropriate, to the care, treatment, and services provided.
EP 2: Medical records contain the following demographic information... the patient’s language and communication needs.
Communication needs is broad (it was changed from primary language to be more inclusive and as a means to begin to get at issues of health disparities)
language
health literacy
sign language/reading lips
In the HLC study, we found that information on communication needs is often not documented uniformly or systematically within and across organizations.
In terms of documenting communication needs, think about:
Where is this information located in the medical record?
Will it be easy for staff throughout the continuum of care to access this information?
Are there other processes in place for tracking patient needs (color coded tags/stickers, etc.)
Are fields mandatory?
Is there a default set (e.g. primary language)

22. Leadership
Standard LD.3.60: Communication is effective throughout the organization.
EP 1: The leaders ensure processes are in place for communicating relevant information throughout the organization in a timely manner.
EP 2: Effective communication occurs in the organization, among the organization’s programs, among related organizations, with outside organizations, and with patients and families, as appropriate.
EP 3: The leaders communicate the organization’s mission and appropriate policies, plans, and goals to all staff.
EP 2 directly addresses communication with patients and families

23. Provision of Care, Treatment,
and Services
Standard PC 6.10: The patient received education and training specific to the patient’s needs and as appropriate to the care, treatment, and services provided.
EP 1: Education provided is appropriate to the patient’s needs.
EP 2: The assessment of learning needs addresses cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication, as appropriate.
Health literacy and communication play a role in all of the standards we’ve been talking about today
However, I would like to not that health literacy is most often scored under these next 2 standards
Issues of assessment & education and how well they are matching up
How are these needs being assessed?
Is there a standard assessment being used across the organization?
Is it self-reported by patients?
What types of materials/education are being provided to match these various patient needs?

24. Provision of Care, Treatment,
and Services
Standard PC 6.30: The patient received education and training specific to the patient’s abilities as appropriate to the care, treatment, and services provided by the hospital.
EP 1: Education provided is appropriate to the patient’s abilities.
EP 3: The content is presented in an understandable manner.
EP 4: Teaching methods accommodate various learning styles.
EP 5: Comprehension is evaluated.

25. Public Policy White Paper: Health Literacy Recommendations
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
The Health Literacy and Patient Safety Roundtable met in May and September of 2005.  The Roundtable was charged with framing the issues related to low health literacy and its impact on patient safety.  The Roundtable discussions culminated in the publication of a white paper, which describes interventions to improve the ability of patients to understand complex medical information, and provide recommendations for a broad range of health care stakeholders and policymakers to mitigate the risks to patients with low health literacy and/or low English proficiency.  The Joint Commission and Joint Commission Resources hosted a national symposium on health literacy and patient safety in June of 2006.  Information gained from the symposium contributed to the content of the white paper
Download this report for free at:

26. Make Effective Communications an Organizational Priority
Sample Solutions for Recommendation 1:
Organizational Culture: Make patient-centered communications/cultural competence a priority
Data Collection/Assessment: Learn the literacy levels/language needs of the community served
Recruitment: Set recruitment goals or establish hiring practices that value diversity
Training: Train/continually educate staff to recognize and appropriately respond to communication vulnerable patients
Patient-Centered Environments: Make all communication points (signage, materials, written/verbal instructions, etc.) patient-friendly
These are just a few examples from The Joint Commission Health Literacy white paper that shows how organizations can meet the three main recommendations

27. Address Communication Needs Across the Continuum of Care
Sample Solutions for Recommendation 2:
Entry: Develop and provide forms and information that are “client centered” – plain language/multi-language
Health Care Encounter: Apply communication techniques known to enhance understanding (plain language, “teach back,” “show back,” etc.)
Transition: Standardize approach to “hand-off” communications
Self-Management: Place outreach calls to patients to ensure understanding of, and adherence to self-management regimens

28. Pursue Policy Changes Promoting Improved Communications
Sample Solutions for Recommendation 3:
Referrals: Refer patients with low literacy to adult learning centers and assist with enrollment process
Collaboration: Encourage partnerships between adult educators, adult learners, and health professionals to develop health-curricula and health interventions
Payment Systems: Pursue pay-for-performance strategies that provide incentives to foster patient-centered communications and culturally competent care

29. 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?

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

31. Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings
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:

32. Key Findings from the 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 of Findings free at:

33. Key Findings from the 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 of Findings free at:

34. 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?

35. One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations
Released April 2008
Download a free copy of the report on HLC website
Thematic framework derived from current practices in 60 hospitals
Download One Size Does Not Fit All free at:

36. Framework for Establishing Practices to Meet the Needs of Diverse Patients
Building a Foundation
Organizational policies and procedures
Role of leadership
Collecting and Using Data to Improve Services
Community- and patient-level data
Collecting data before, during, after services
Accommodating the Needs of Specific Populations
Services targeted to large populations in the community
Establishing Internal and External Collaborations
Bringing together multiple departments, organizations, providers, and individuals

37. 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

38. Chapter 8: Self-Assessment Tool
Created to help hospitals and other health care organizations evaluate the way they currently provide care to diverse patients
Intended to address the main issues emerging from the HLC study; organized by 4 themes highlighted in report
Questions designed to promote discussion around the need to improve or expand current initiatives to meet C&L needs
Engage diverse staff members from different sectors of organization 38

39. Other Resources from the HLC study
A study to help understand what drives some hospital CEOs to embrace language, culture, and health literacy improvement initiatives
Ongoing research on the experience of Juan Lopez, a limited English proficient patient, at 60 hospitals across the nation
Joint Commission surveyor education, including a collaboration with the Office for Civil Rights to develop a video and learning module focused on Title VI of the U.S. Civil Rights Act and Section 504 of the Americans with Disabilities Act 39

40. 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.

41. 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

42. Complementary Projects in the Field
National Quality Forum (NQF)
National Voluntary Consensus Standards for a Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency
Recommends 45 practices for endorsement along with a comprehensive national framework for measuring and reporting cultural competency
National Committee for Quality Assurance (NCQA)
Cultural and Linguistic Access Standards Advisory Committee
Develop a cohesive module of standards for evaluating efforts to improve the provision of culturally and linguistically appropriate services
Intent to release the standards in 2009

43. Issues to Address
Prioritize effective communication and make commitments highly visible to staff and patients
Assess your current practices, communications, environment, patient needs, etc.
Implement policies that support effective communication
Assess patient needs and implement a uniform framework for collecting of data on race, ethnicity, language, and health literacy
Train staff or create tools that will help staff learn the appropriate procedures for assisting communication-vulnerable patients
Effective communication needs to be prioritized within organizations
This can be operationalized in different ways
Mission, vision, value statements
Organizational Planning
What is important is that these commitments or priorities are visible and clearly communicated to staff and patients
Make it clear that everyone plays a role
During site visits, we had staff tell us that language & culture issues are important, but it doesn’t have anything to do with them
Policy example:
Do not permit the use of family members, esp. minors, for interpreting during medical encounters except in an emergency when no other option is available
Data collection – making sure it is uniform, accessible, and consistent
Staff Training:
Providing education & tools to help staff implement effective communication
For all individuals used to interpret, assess English and target language proficiency and require or provide training on health care interpreting

44. Issues to Address
Provide ongoing in-service training on ways to meet the communication needs of the patient population
Implement informed consent processes to include forms in simple sentences and in the language of the patient; use “teach back” and engage the patient in a dialogue about the procedure
Formalize processes for developing plain language patient education materials and for translating materials, including patient rights and informed consent documents
Collaborate with other health organizations or community groups to create or share resources
Making sure that training is a continuous process
Training needs to be ongoing – not just in orientation
When possible some type of assessment or evaluation should be included
Informed consent
Making it a process not just a form
Think about communication & assessing understanding
Discussions
Teach back
Use health care interpreters to facilitate communication with LEP patients during all informed consent processes; use cultural brokers when a patient’s cultural beliefs impact care
Translating – American Translators Association has a guide available for helping choose translation service
Collaboration
share information – best practices & lessons learned
Make use of community resources – adult learning programs

45. For More Information
Hospitals, Language, and Culture study website:
Available:
Downloadable reports
Hospitals, Language, and Culture study information
Culturally competent patient-centered care standards information
Links to other websites
Resources
Christina L. Cordero, PhD, MPH

46. Questions??
What have your experiences been with Joint Commission surveys around these issues?
Have Joint Commission surveyors shown interest in these issues?
Do you have any examples of innovative ways that your organization or an organization you have seen addresses the challenging issue of effective communication?
Are there any resources you would share with other organizations to help them implement practices around effective communication?
The Joint Commission currently has a proposal out to develop standards for cultural competence
Do you have any suggestions for what you would like to see in these standards?
What information or resources do you feel The Joint Commission could provide organizations to help them in the areas of effective communication that we talked about today?