Cultural Competence in Health Care: Overcoming Language Barriers as a Strategy to Improve the Safety

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Cultural Competence in Health CareOvercoming
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

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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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Video Clip
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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 limited English proficient
  (LEP) and hearing impaired (HI) patients

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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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Video Clip
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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.

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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.

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Federal Mandates and Legislation

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

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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.

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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.

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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.

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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.
  

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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.

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Patient Safety and Healthcare Quality

• Several states have introduced legislation
  forbidding children under sixteen from serving as
  interpreters.

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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.

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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."

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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.

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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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Video Clip
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Discussion

• What issues arose during this scenario?

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Video Clip
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Discussion

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

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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.

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Best Practices The Johns Hopkins Hospital
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Best Practices The Johns Hopkins Hospital
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Best Practices The Johns Hopkins Hospital

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

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Best Practices The Johns Hopkins Hospital

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

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Best Practices The Johns Hopkins Hospital
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Best Practices The Johns Hopkins Hospital

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

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Best Practices The Johns Hopkins Hospital
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Resources

• National Standards on Culturally and
  Linguistically Appropriate Services
  (CLAS)http//www.omhrc.gov/templates/browse.aspx?
  lvl2lvlID15

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Resources

• Limited English Proficiency A Federal
  Interagency Websitehttp//www.lep.gov/resources/r
  esources.html
• Hablamos Juntos Language Policy and Practice in
  Health Carehttp//www.hablamosjuntos.org/
• See Universal Symbols in Health Care
  Workbookhttp//www.hablamosjuntos.org/signage/PDF
  /Best20Practices-FINALDec05.pdf

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Resources

• Diversity Rxhttp//www.diversityrx.org/
• A Patient-Centered Guide to Implementing Language
  Access Services in Healthcare Organizationshttp/
  /www.omhrc.gov/Assets/pdf/Checked/HC-LSIG.pdf
• Joint Commission Hospitals, Language, and
  Culturehttp//www.jointcommission.org/PatientSafe
  ty/HLC/

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Resources

• Oral, Linguistic, and Culturally Competent
  Services Guides for Managed Care
  Planshttp//www.ahrq.gov/about/cods/cultcomp.htm
• Providing Oral Linguistic Services A Guide for
  Managed Care Planshttp//www.ahrq.gov/about/cods/
  oralling.htm

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Video Clip
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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 at
  crt.lep_at_usdoj.gov or Sharon Williams at
  Sharon.V.Williams_at_usdoj.gov
• CDs and associated materials are available for
  free

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Questions

• ???

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For additional information, contact

• Cheri Wilson, cwilso42_at_jhmi.edu