© copyright, the joint commission one size does not fit all: meeting the health care needs of...

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One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations

Amy Wilson-Stronks, MPP, CPHQPrincipal InvestigatorHospitals, Language, and Culture studyDivision of Standards and Survey MethodsThe Joint Commission

2008 MIAB Conference

The $ and Sense of Culturally Effective Care: Access, Communication, and Commitment

October 31, 2008

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Today’s Journey Through the Eyes of a Patient – Meet Juan Lopez

60-year-old Mexican immigrantDoesn’t speak EnglishLimited experience with the U.S. health

care system12-year-old English-speaking daughter

Juanita

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Our Story Begins…

Juan Lopez presents to Hospital X’s Emergency Department, accompanied by his daughter Juanita.

He is writing in pain and clutching his stomach.

He declares to the triage nurse,

“!Mi vecino me puso una brujeria!”

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Who Juan Lopez Encounters:

Triage nurseEmergency department physician Emergency department nurseRadiology techMedical surgery unit for recovery

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Ideally, how would staff communicate with Juan Lopez at your

organization?

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Ideally, how would staff respond to the hex at your organization?

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Communication is the Cornerstone of Patient Safety

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The Need for Accurate Information

Assess patient needsDetermine diagnosis/prognosisProvide TreatmentObtain consentEducate/InformHand-off communications

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Multiple Players in Communication

Patient/familyPhysiciansNursing PharmacyPhysical

TherapistsSpeech

Therapists

Occupational Therapists

Social WorkersPsychologistsLabImagingBilling

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Factors That Can Inhibit Communication Abilities

Hearing impairmentVisual impairmentCognitive Limitation IntubationDisease (ALS, Stroke)Health ProxyCulture Literacy Language

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Poor Communication Impacts Patient Safety

Communication vulnerable patients are at increased risk for:

– Serious medical events (Cohen et al., 2005)

– Sentinel events (The Joint Commission, 2007)

– Poor medication compliance/ adherence (Andrulis et al., 2002; Flores et al., 2003)

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Root Causes of Sentinel Events

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Cross-sectional qualitative study

Three Research Questions:

1. What are the challenges hospitals face providing care to diverse patient populations?

2. What are hospitals doing to address these challenges?

3. Are there any promising practices that can be replicated to improve care?

Hospitals, Language, and Culture:A Snapshot of the Nation (HLC)

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300+ beds: 32

25-99 beds: 10

Teaching/Academic: 22

Rural: 15

Urban: 35

Public: 15

Non-profit:32

HLC Sample Hospitals (n=60)

100-299 beds: 18

Region (representing 32 states)

West21

Midwest12

South17

Northeast10

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Cross-sectional qualitative study of 60 hospitals– 2 samples of 30 hospitals

In-person administrative interviews– CEO (one-on-one)

– Leadership, Human Resources, Cultural and Language Services (3 groups of 3 representatives)

In-person clinical interviews – Patient-centered assessment interviews focused on a

clinical case scenario (one-on-one)

HLC Study Methodology

Source: Hospitals, Language, and Culture Study, A.Wilson-Stronks et.al, 2008

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Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A 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 free:

http://www.jointcommission.org/patientsafety/hlc

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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

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

Download the report free: http://www.jointcommission.org/patientsafety/hlc

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Leadership Support: A Key to Success

Insights from Hospital CEOs

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Recommendations: The Role of Leadership

Establish a centralized program to coordinate culture and language services

Make the commitment to culturally and linguistically appropriate care highly visible

Have internal multidisciplinary dialogues

Research is needed to better understand what drives hospital CEOs who embrace culturally and linguistically appropriate care

Source: Wilson-Stronks A, Galvez E. Exploring cultural and linguistic services in the nation’s hospitals: A report of findings. Oakbrook Terrace, IL: The Joint Commission; 2007.

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Recommendations: Collecting and Using Data

Implement a uniform framework for the collection of data on race, ethnicity, and language.

Stratify service and technical quality measures such as those reported through the Hospital Quality Alliance, by language, race, and ethnicity


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Recommendations: Provision of Language Services & Workforce

Establish and implement written policies that do not permit the use of family members/ad hoc individuals to interpret

Assess English and target language proficiency of all individuals used to interpret

Incorporate language service programs into safety and quality efforts - PI structures and tools

Provide ongoing training on how and when to access language services


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Recommendations: Provision of Care & Community Engagement

Formalize processes for translating written materials (patient rights, informed consent, etc.)

Use health care interpreters and cultural brokers to facilitate communication

Take advantage of internal and external resources available to learn about cultural beliefs

Make staff aware of the tendency toward stereotyping to avoid assumptions about patients

Make use of community resources through networks, collaborations, and partnerships


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How Can the Findings Be Used?

The recommendations recognize that an integrated effort among hospitals, policymakers, and researchers is required.

Can use findings as benchmark and use recommendations to conduct gap analysis.

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Cross-sectional qualitative study

Three Research Questions:

1. What are the challenges hospitals face providing care to diverse patient populations?

2. What are hospitals doing to address these challenges?

3. Are there any promising practices that can be replicated to improve care?

Hospitals, Language, and Culture:A Snapshot of the Nation

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Released April 21, 2008

Download a free copy of the report on HLC website

Thematic framework derived from current practices in 60 hospitals

One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations

Download this report free at: http://www.jointcommission.org/patientsafety/hlc

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Developing a supportive infrastructure for cultural competence– Cultural competence in organizational planning– Developing policies for cultural competence

Integrating culture and language (C&L) into organizational systems– Recruiting and sustaining a diverse workforce– Creating a high-level task force– Structuring budget systems for culturally and

linguistically appropriate care Integrating cultural competence into patient care

– Providing appropriate language services

Theme 1 - Building a Foundation

Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008.

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Theme 1 - Building a Foundation

“It’s one thing to put it in a mission and vision statement and plaster it on the wall and to say we serve all people in the community regardless of ethnicity or race; it’s another thing to actually do it.”

–CEO from a northeastern hospital

“I think the biggest challenge is making certain that staff and employees [practice] cultural sensitivity. This is a people business and as much as the CEO might issue an edict…[cultural sensitivity] does not happen unless you invest in your employees.”

–CEO from a western hospital


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Assessing the need for C&L services– Collecting community- and patient-level data

Monitoring C&L service utilization– Collecting data on service use

– Building upon C&L service utilization data

Using data to improve C&L services– Establishing a baseline of services

– Obtaining patient feedback

– Stratifying data by demographic variables

Theme 2 - Collecting and Using Data to Improve Services


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“Collection of data is critical. Data shows you who your population[s] [are] and what languages these populations speak. Further [scrutiny] of the data allows the facility to see what services they are most apt to seek…. Data allows [human resources] to conduct an annual comparison of employee mix to community and patient load. If the patient data does not proportionately match the community data, then the facility must ask if there is a reason why that population is not accessing services.”

–HLC Technical Advisory Panel member

Theme 2 - Collecting and Using Data to Improve Services


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Staff awareness through training, dialogue, and support– Training on effective communication, cultural competence– Providing staff with educational resources

Creating an environment that meets specific needs– Enhancing the hospital’s physical space– Adapting services to address cultural beliefs

Helping patients manage their care– Navigating the health care system– Providing patient education

Establishing centralized programs that meet specific needs of large populations– Culturally and religious/spiritually centered

Theme 3 - Accommodating the Needs of Specific Populations


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“[The doula program] came out of dialogue with women from the community that we were able to bring in [to] talk about their birth practices [and] our birth practices…. We literally sent vans out to go pick women up and bring them here to have a dialogue. It was as informal as that. It [developed] into the doula program that we [now] have.”

–A member of C&L services from a midwestern hospital

Theme 3 - Accommodating the Needs of Specific Populations


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Working together within the hospital– Establishing a cultural diversity committee

– Bringing diverse stakeholders together Building bridges with other hospitals

– Sharing, pooling existing resources Engaging the community

– Community partnerships to create a diverse workforce

– Using community leaders to bridge cultural barriers

– Becoming an active member of the community


Theme 4 - Establishing Internal and External Collaborations

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“We are part of a local collaborative, where six or seven different health care systems have come together and said, ‘We don’t all need to translate all of our diabetic and education information into these six or seven languages. Why don’t you take on doing half of those, and we’ll do half of those, and let’s take our letterhead off of that information.’ We can use that information across the system.”

–A member of C&L services from a midwestern hospital

Theme 4 - Establishing Internal and External Collaborations


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Hospitals, Language, and Culture: A Snapshot of the Nation’s Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings

American Medical Association, Ethical Force Program’s Improving Communication—Improving Care: How Health Care Organization Can Ensure Effective, Patient-Centered Communication with People from Diverse Populations

Office of Minority Health’s National Standards for Culturally and Linguistically Appropriate Services in Health Care

The Joint Commission’s “What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety

Supporting References for Practices

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The Big Question: How can the practices in this report help my organization better serve

our diverse patients??

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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

Chapter 8: Tailoring Initiatives to Meet the Needs of Diverse Populations


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Focus groups

In-services

Lunch meetings

Seminar series

Small-group interviews

Staff retreat

Targeted interviews

Methods for Self-Assessment


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Potential Participants

Chief executive, medical, nursing, operating officers

Community members Dietary services Diversity officer Financial assistance/ billing

staff Hospital chaplain Human resources director Information technology staff Intake staff

Language services coordinator

Medical and nursing staff Patient advocates Patient safety officer Patients and families Quality improvement officer Recruiter Risk management officer Social services Staff/clinical educator


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Sample Questions from Self-Assessment Tool

Building a Foundation– How does our leadership currently support the provision of

culturally competence care? Collecting and Using Data to Improve Services

– How have we assessed the C&L needs of the community? Our patients?

Accommodating the Needs of Specific Populations– What aspects of the physical environment have been

evaluated to determine whether they meet specific patient needs?

Establishing Internal and External Collaborations– What community organizations or networks, religious

leaders or chaplains, or traditional healers can we collaborate with to meet patient needs?


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2-hour workshop with an organization’s cultural diversity committee

Questions from Theme 1 – Building a Foundation

3 facilitated small group sessions

Large group discussion of responses

Received positive feedback (n=25)– Participants indicated it was a useful exercise– The tool helped people learn more about their organization– Overall the questions were understandable

Field Test of the Self-Assessment Tool

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Evaluation form available as an electronic survey on HLC website; paper copies in published reports

Organizations are encouraged to provide feedback after using the self-assessment tool:– How did your organization use the tool?

– Who was involved?

– How useful do you feel the tool is?

– What type of organization are you from?

– Where is your organization located?

– Additional comments and suggestions for improvement

We want your feedback!

Survey available at: http://www.jointcommission.org/patientsafety/hlc

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Thematic framework derived from current practices in 60 hospitals

Self-assessment tool to tailor initiatives to meet the needs of diverse patient populations

Cultural competence is an ongoing journey - hospitals should assess and re-assess the services they provide

Summary – One Size Does Not Fit All

Download this report free at: http://www.jointcommission.org/patientsafety/hlc

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Evolution of Joint CommissionStandards Supporting CLAS

Identification of certain rights for all patients Increased patient awareness related to

patients’ participation in careCultural competence is more than a patients’

rights issue; it is critical to safety and quality of care

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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.

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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

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Hospitals, Language, and Culture study website: www.jointcommission.org/patientsafety/hlc/

Available:Downloadable reportsHLC study informationLinks to other websitesResources

Amy [email protected]

For More Information

© copyright, the joint commission one size does not fit all: meeting the health care needs of...

Documents

joint commission communication

joint commission factors

recovery slide

nation hlc slide

challenges hospitals

patient needs

juan lopez encounters

diverse patient populations