Transcript Slide 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
Objectives
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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
Video Clip
Scope of the Problem:
U.S. Demographics
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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
Scope of the Problem:
U.S. Demographics
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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.
Video Clip
Federal Mandates and Regulations
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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
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However, neither of these mandates includes
funding and the burden of the cost of
language services remains the responsibility
of the provider.
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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.
Federal Mandates and Legislation
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The lack of availability of qualified, medical
interpreters and inadequate funding are two
major impediments to providing language
services.
Patient Safety and Healthcare Quality
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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
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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
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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.
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This study found that a greater percentage of LEP
patients experienced physical harm versus Englishspeaking 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
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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.
Patient Safety and Healthcare Quality
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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.
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For example, California Assemblyman Leland Yee
remembers translating for his mother at the
doctor's office when he was only six years old.
Patient Safety and Healthcare Quality
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Several states have introduced legislation
forbidding children under sixteen from
serving as interpreters.
Patient Safety and Healthcare Quality
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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.
Patient Safety and Healthcare Quality
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Occasionally, a bilingual health care provider
may be present.
However, this is not without its problems as
well.
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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."
Patient Safety and Healthcare Quality
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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.
Patient Safety and Healthcare Quality
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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.
Video Clip
Discussion
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What issues arose during this scenario?
Video Clip
Discussion
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How was this scenario improved with the
assistance of a trained, staff interpreter?
Best Practices:
The Johns Hopkins Hospital
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Per the Interdisciplinary Clinical Practice Manual
(ICPM) policy, PAS002: Interpreting Services, foreign
and sign language interpreters are available to
patients.
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For foreign languages, call Johns Hopkins International
Services at 4-INTL (4-4685)
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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.
Best Practices:
The Johns Hopkins Hospital
Best Practices:
The Johns Hopkins Hospital
Best Practices:
The Johns Hopkins Hospital
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The Emergency Department is piloting the
use of a robot for Spanish-language
interpretation.
Best Practices:
The Johns Hopkins Hospital
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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
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In addition, Patient Education materials are
available in English and Spanish in
Micromedex CareNotes™.
Best Practices:
The Johns Hopkins Hospital
Resources
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National Standards on Culturally and
Linguistically Appropriate Services (CLAS)
http://www.omhrc.gov/templates/browse.aspx
?lvl=2&lvlID=15
Resources
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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/
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See: Universal Symbols in Health Care Workbook
http://www.hablamosjuntos.org/signage/PDF/Best
%20Practices-FINALDec05.pdf
Resources
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Diversity Rx
http://www.diversityrx.org/
A Patient-Centered Guide to Implementing
Language Access Services in Healthcare
Organizations
http://www.omhrc.gov/Assets/pdf/Checked/HCLSIG.pdf
Joint Commission: Hospitals, Language, and Culture
http://www.jointcommission.org/PatientSafety/HLC/
Resources
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Oral, Linguistic, and Culturally Competent
Services: Guides for Managed Care Plans
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
Video Clip
Resources
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To order the video, Breaking Down the
Language Barrier: Translating Limited
English Proficiency into Practice
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Contact the Department of Justice at:
[email protected] or Sharon Williams at:
[email protected]
CDs and associated materials are available for
free
Questions
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For additional information, contact:
Cheri Wilson, [email protected]