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, CPHQ Quality Improvement Team Leader The Johns Hopkins Hospital

Objectives
This presentation will provide an overview of: The effects of language barriers on patient safety and healthcare quality The needs of limited English proficiency (LEP) patients The importance of using non-English materials and providing access to language services Experiences, lessons learned, and success stories from Johns Hopkins Hospital and other organizations

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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 LEP patients

Scope of the Problem: U.S. Demographics

Almost 35 million U.S. residents are foreign born. Almost 55 million people (19.7% of the U.S. population) speak a language other than English at home. More than 24 million people (8.7% of the U.S. population) speak English less than "very well" and are considered LEP.

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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.

Federal Mandates and Regulations

However, neither of these mandates includes funding. The burden of the cost of language services remains the responsibility of the provider. An American Medical Association (AMA) survey found that the cost of interpreter services ranged from $30 to $400 per hour, while the average Medicaid office visit reimbursement was only $30 to $50. Private payers generally do not reimburse for interpreter services.

Federal Mandates and Legislation

Two major impediments to providing language services are: Lack of availability of qualified, medical interpreters, and Inadequate funding

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.

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.

Patient Safety and Healthcare Quality

A study analyzed 1,083 adverse incident reports from six Joint Commission-accredited hospitals for English speaking vs. 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.

Patient Safety and Healthcare Quality

In an effort to provide language services, healthcare providers have sometimes resorted to drastic measures. 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.

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.

Patient Safety and Healthcare Quality

In many instances, a family member serves as an interpreter, which raises privacy and other concerns. For example, California State Senator Leland Yee remembers translating for his mother at the doctor's office when he was only six years old. Several states have introduced legislation forbidding children under sixteen from serving as interpreters.

Patient Safety and Healthcare Quality

Untrained interpreters are more likely to commit errors in interpretation that can lead to adverse clinical consequences.

Patient Safety and Healthcare Quality

Concerns about untrained interpreters include:

Lack of 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.

Patient Safety and Healthcare Quality

Occasionally, a bilingual healthcare 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 (Se peg) as "I hit her" instead of "She hit herself."

Patient Safety and Healthcare Quality

Care can be compromised or delayed in the absence of any language service (trained or untrained). In other instances, the consequences can be catastrophic.

Patient Safety and Healthcare Quality

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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Discussion
What issues arose during this scenario?

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

Best Practices: The Johns Hopkins Hospital

Per the JHH 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 410955-2273.

Best Practices: The Johns Hopkins Hospital

According to the policy, interpreters must be provided to patients and/or family members under the following circumstances:
Obtaining the patients medical history; Explaining the plan of care and periodic updates on the plan of care Discharge planning discussions Explaining procedures

Best Practices: The Johns Hopkins Hospital

According to the policy, interpreters must be provided to patients and/or family members under the following circumstances:
Obtaining consent; Providing patient education, including discharge instructions; and Having discussions about advance directives.

Best Practices: The Johns Hopkins Hospital

Best Practices: The Johns Hopkins Hospital

Best Practices: The Johns Hopkins Hospital

Johns Hopkins International has translated certain patient education materials into various foreign languages.

Best Practices: The Johns Hopkins Hospital

Best Practices: The Johns Hopkins Hospital

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

Best Practices: The Johns Hopkins Hospital

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

Resources
Limited English Proficiency: A Federal Interagency Website
http://www.lep.gov/resources/resources.html

Hablamos Juntos: Language Policy and Practice in Health Care

http://www.hablamosjuntos.org/ Also see: Universal Symbols in Health Care http://www.hablamosjuntos.org/signage/sy mbols/default.symbols.asp

Resources
Speaking Together: National Language Services Network http://www.speakingtogether.org/ National Health Law Program: Language Access in Health Care Statement of Principles http://www.healthlaw.org/library/item.71365

HRET Disparities Tool Kit: A tool kit for collecting race, ethnicity, and primary language from patients http://www.hretdisparities.org/

Resources
Diversity Rx
http://www.diversityrx.org/ Quality Healthcare for Culturally Diverse Populations Conference
http://www.diversityrxconference.org/

A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations

http://www.omhrc.gov/Assets/pdf/Checked/H C-LSIG.pdf

Resources
Joint Commission: Hospitals, Language, and Culture: A Snapshot of the Nation
http://www.jointcommission.org/NR/rdonlyres/E64E5 E89-5734-4D1D-BB4DC4ACD4BF8BD3/0/hlc_paper.pdf

Joint Commission: One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations
http://www.jointcommission.org/PatientSafety/HLC/on e_size_meeting_need_of_diverse_populations.htm

Resources
Oral, Linguistic, and Culturally Competent Services: Guides for Managed Care Plans
http://www.ahrq.gov/about/cods/cultcomp.htm

Providing Oral Linguistic Services: A Guide for Managed Care Plans

http://www.ahrq.gov/about/cods/oralling.htm

Resources
White Paper: For the Health Care CEO: Thinking about Language Access in Health Care by Edward L. Martinez, MS
http://www.pgsi.com/Products/Resources/Whi tePapers/WhitePaper1.aspx

Resources
Open invitation to comment on the National Quality Forums proposed Framework and Preferred Practices for Measuring and Reporting Cultural Competency
http://www.qualityforum.org/projects/ongoing/ cultural-comp/ Public comments due by November 5, 2008.

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Resources
To order the video, Breaking Down the Language Barrier: Translating Limited English Proficiency into Practice
Contact the Department of Justice Civil Rights Divisions Coordination and Review Section at (202) 307-2222 or crt.lep@usdoj.gov CDs and associated materials are available for free

Questions

For additional information, contact Cheri Wilson at: cwilso42@jhmi.edu or 410-502-6025.