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1 A G U E G , A N N A D L , C S L U A L T T One Si ze Does Not Fit Al l: I U P S R E O H Mee ti ng the Hea lth Ca re Nee ds of Diver se Popul ati on s n A o i S t n a a N p s e h h o t t f o Karen L. Cordero, K. Lee, Christina Amy Wilson-Stronks, and Erica Galvez April L. Kopp,

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3 Table of Co nt ent s St af fand Ac knowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Tec hni ca lAd visory Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Abo ut the Aut hors Exec ut ive Su mmary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Cha pt er 1 Intr oduct ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Cha pt er 2 Meth odo lo gy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 A Fr amewo Cha pt er 3 of Diver se Popul ations . . .14 rk fo r Esta blis hing Pra ctic es to Meet the Needs Cha pt er 4 Bui ldi ng a Fo undat io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Cha pt er 5 Colle cti ng and Usi ng Da ta to Im pro ve Se rvices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Cha pt er 6 Accomm od at ing th e Needs of Sp ecific Po pul ations . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Cha pt er 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Esta bl ish ing Inte rnal and Exte rn al Co ll abo rations Cha pt er 8 Tai lorin g In itia ti ves to Me et the Needs of Div erse Popu lati ons: A Sel f-A sse ssme nt To ol . . .45 App end ix A Endno tes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 App end ix B Glossar y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 3 nd Ho Support fo r the Langu a ge, a spi Culture study is provide d by a grant tals, fr om The Cal ifo rn ia Endowmen t.

4 MEN TS STAFF and AC KNOWLEDGE Hosp ital s, La ng uag e,andCu lture Pr ojec t Sta ff Am y Wilso nks , MPP , CPH Q, Principal Investigator n-Stro Ph D, MP H, Se ni or Research Chri stina L. Cordero, As so ciate Ka ren K. Lee, MS, Senior Re search Asso ci ate Isa Ro dri gu ez , Seni or Secre tary April L. Ko pp, MF A, Cons ultant Researc ors h Advis sion Mau ree n Car r, MBA, Proje ct Dire cto r, The Joint Commis ion Sh elby Dunster, BA , Di rect or, The Joi nt Commiss Eri ca Ga lvez , MA , Associat e Proje ct Dire ctor, The Joint Commis si on Ac kn owl ed geme nts Pa rtic ip at in g Hosp ita ls Pr ojec t Advi sors We woul d li ke to gi ve speci al th ank s to the 60 hospit als Feli cia Batts, MPH s that par ti cipate d in this stu dy and th e hos pital liaison nia, PhD Romana Hasna in-Wy wh o coor din at ed al l of the activit ies rela ted to the si te Eli zab eth Jacobs , MD, MP P vi si ts. As agr eed at th e comme nce ment of th is study , we Su nita Muth a, MD , FAC P ar e not relea si ng the na me s of th es e hos pi ta ls, but we Revie wers wis h to ackn owle dge th em fo r th eir effo rts to fu rther the We woul d li ke to ac kn owl edge the ma ny in dividuals unde rs ta ndi ng of provi di ng cultu rally compe te nt care . wh o pro vid ed thou gh tful revi ew of thi s repo rt: Wilma Sp ecia l Thank s Bat ts, ttle, P. Andr ulis, Felicia Al varado-Li De nnis We wo uld li ke to ac knowle dge Paul M. Sch yv e, Senio rVice Ca rr, Lynn Fors , Ign ati us Bau, Barb ara Bra un, Maureen Pr esi dent ; Rob ert A. Wi se, Vi ce Presid ent , Divisi on of Louis Frederick C. Hamp ers, Romana Hasnain-Wynia, Sta nd ard s and Survey Me thods; and Amy Pan ag opo ulo s, Hob by , Elizab et h Jacob s, Robe rt C. Li ke, Edwar d L. Di recto r, Divi si on of Sta ndar ds and Surv ey Method s, at The ne z, Jenn ifer Matia Marti sek , Lub en Monto ya, Jason Joint Com mi ssi on for th ei r gui da nce and en co ura geme nt. Mark Roat, da Parti da, Cyn thia Orms by, Yolan Ruk avina , Karin Rusch ke, Gay le Tang , Sue Win tz, and We woul d als o like to th an k Ign atius Ba u, Direct or Mara K. Youd elm an . at Th e of Cu lt ura lly Comp ete nt He alth Syst ems Ca lif or nia End ow ment , for his co nt in ued su ppo rt . Edi toria l Supp ort Wit ho ut hi s vision , we woul d not ha ve be en ab le to con - ia l supp ort of Johanna Ma ny than ks for the editor duct th is stud y. Ro se nbo hm. Gra ph ic Desig n Bill Buller man Sug gested Ci tat ion Wils on- Stronk s A, Lee KK , Cor de ro CL, Kopp AL, Galvez E. On e Size Do es Not Fi t All : Mee ti ng The Health Care sion; 2008. Ne ed s of Di ve rse Po pulati ons. Oak bro ok Terrace, IL: Th e Joint Commis 4 by The Joint Commi ssi on. All right s reserv ed. This report is available for download on The Joint © 2008 Com missio n’ s websi te at www.jo int commi ssion .org/P at ientSafety /HLC/ . Perm iss ion to rep roduce ed ucat ional purpos es with displ ay of attr ibution is thi s rep ort for noncommercial, 792-5954. ts reg ar di ng per mission to reprint, please cal l (630) gran ted . Fo r oth er reques

5 TECH NICAL AD VISOR YPAN EL Lindsa y K. Ma nn, FA CHE is, PhD, MP H De nni s P. Andrul Ka we ah Delta Hea lth Care Di stri ct Cent er for Health Uni ve rsit y Equali ty, Drexel Schoo l of Pu blic He alth rd L. Mar tin ez , MS Edwa He alth Ma na ge me nt Co ns ul tant Fe lic ia A. Ba tts, MPH Co nsul ti ng By De sign Suni ta Mutha, MD , FAC P Uni ve rsi ty of Ca lifo rni a – San Fr anc is co Ig na tius Bau , JD The Ca lifor nia Endo wment Gua dal upe Pac he co, MS W ent Offi ce of Mino ri ty Heal th , U.S . De partm RN Mary Lou Bon d, PhD, of Healt h and Hum an Ser vi ces at Ar li ngton Uni ver sity of Texas MSW, DPA Pa rtida, Yo landa JD , MD , MBA, Sa muel S. Fager Habl amo s Junt os In dep end ent Co nsu ltant Mark Ru kav ina, MBA Heng Lam Foon g The Acce ss Proj ec t Land, Health y Park s, The Trust fo r Public nities Hea lt h Commu Ka rin Ru schk e, MA Inte rnat iona l La nguage Servi ces, Inc. R. Gr een, MD, MPH Al exander Cen ter , The Disp ari ti es So lutions Sus an C. Scr im shaw, Ph D Ma ssa chuse tts Gene ral Hosp ital Simmo ns Co ll ege Louis C. Hamp MBA, FAAP ers, MD, Cr aig Spive y, MSW The Ch ildre n’s Ho spi tal of Denv er Pr oj ect Brot herh oo d Hasn ain -Wyni a, PhD Romana Gay le Ta ng , MS N, RN Cent er for Health ca re Equi ty, Feinbe rg Schoo l Ka ise r Perm ane nte of Medi cine , No rt hwestern Uni ver sit y Mar a K. Youde lm an , JD, LL M Sa nd ral Hull ett, MD, MP H Na ti onal Hea lth La w Pro gram Co op er Green Hos pital El izabeth A. Ja cob s, MD, MPP tal of Cook The Joh n H. Stro ge r Jr. Hospi Co unty, Rush Uni ver sity Medi cal Center 5

6 ABOUT TH EAUTHO RS Am yWi lson -Stro nk s, MPP ,CP HQ ties work Amy at The in the Divis io n of Sta nda rds and Survey is the pr oj ect dir ec tor for hea lth dispari Me thods Lang uag e, and Cult ur e tor of the Join t Commi ssi on and is th e pr in cip al inv estiga (HLC) Hospitals, stu dy. Sh e is acc reditation related and evaluate to cultur ally and di recting standards the wo rk of The Joi nt Commi ssion to assess iss ues for Joint li ngui sti cally ap pro pri at e ser vice s, and is de ve lopin g a com prehen sive train ing progr am on these Comm on subject s relat ed to cultural is sio n surv eyo rs. She al so se rves on a number of national advis or y com mittees of public degree in heal th pol icy and a gradu - com petence policy and pati ent -ce ntere d care. Amy ear ned a master ied Profes si onal of Chic ago, and she is a Certif at e ce rt ifica te in he alth adm inistratio n and po licy fro m the Un iversity in Health ca re Quali ty (CP HQ ). Ka re nK. Le e, MS work - Kar en is a senio r res ear ch assoc iate in the Div isio n of St anda rds and Surve y Meth ods at The Jo int Comm ission, ission, in g on resea rc h, tra inin g, and dissem she in at ion act ivi ti es for the HLC stu dy . Be fo re jo ining The Joint Comm dev el op ed con su me r-o ri en ted mul time dia ed uc atio nal ma terials with St ate of the Art, Inc., on vari ous he alth topics an d ex plored iss ues of heal th co mm un ic ation and hea lth dispa rit ie s at th e Da na Fa rbe r Cancer Ins titute. Karen earne d he r maste r of scienc e in pub li c he al th fro m Harvard Univer si ty . Chri st inaL. Co rd ero, Ph D,MPH of Standards and Survey Meth od s at Th e Joint Com mission, Tin a is a seni or re search as soci ate in the Division work - stud y and pro vi di ng rese arch and tech nical suppo g projects an d training activit ies. ing on th e HLC rt for ongoin at North wes tern University’s Feinberg School of Pre vio usly , sh e co nd uct ed basi c sci ence and publi c health research Vibr io cholerae RTX toxin in ch oler a dis ease. Tina ea rned both her doctor of Med icine , el ucid ating the rol e of the gy and mi cro bial pathogenesis phi loso ph y in immunolo from Northwestern and her master of publ ic healt h degrees si ty. Univer April L.Ko pp, MA ,MF A st udy. She earn ed her master of arts degree in clin ical soc ial work at the Un ivers ity Ap ri l is a con su ltan t fo r th e HLC from the Univers ity of Iowa. She has worke d for of Ch ica go , an d she ear ne d a maste r of fine ar ts de gree in writing VA Hospital as wel l as th e University Hy gien ic Labor at or y at Hines the VA Inf or mati on Res our ce Cent er (V IReC) of Iow a, and sh e fo rme rly codi re cte d a no nprof it organization, The Patien t Voice Projec t, with Aus tin Bunn . She is A d voc ate s’ For um , a gr ad uate social work journal of th e Univer sity of Chicago School of Social Service a coed ito r of Admin istr ati on. Eri ca Ga lve z, MA Safety, Resear ch at The Joint Patient an d Innovation Eri ca is an asso ci ate pro ject dire cto r in the Cent er for Quality, of health ca re qual it y and sa fety , wi th a specif ic empha Co mm issi on. Her curr en t re se arc h foc use s on various aspects - The Joint Commission , she wor ked for the Tri-Ethnic Center for sis on vu lnera ble po pulat ions. Pr ior to joining n Res ea rch and co nduct ed publi c policy research in Mexic o an d th e United Kingdom. She is the coauthor Pre ventio her master Exp lori ng Cultural Hospitals : A Rep ort of Findi ngs. Er ica earned an d Ling uistic Serv ices in the Nation’s of 6 of Colorado – Boul der. of ar ts deg re e in poli ti cal sci ence fro m the Univ ersity

7 EXECUTI VE SUMMA RY for impro vi ng cu ltur al co mp eten ce withi n hosp itals r heal th disparities Rac ial and ethnic are linked to poore and /o r di rec tly mee ting the C& L nee ds of dive rse pati ent ge and y ca re. Langua and lower qualit heal th outcomes . Th es e po pula ti ons as reporte d by inte rvi ew parti cipants can have a significa cult ural issues nt impa ct on th ese dis - pr acti ces we re revi ewe d by th e HL C Te ch nic al Advis ory by healt h care or gan iza tion s pa rit ies when not add ressed ces wer e th en revi ew ed to identi fy com - Pa nel. The practi [1]. As the div ers ity of our nation hos - con tin ues to grow, Tog et her , the four them es that em er ge d mo n th emes. pi ta ls ar e en co un te ri ng more ge and pat ient s wit h langua meth od co nsti tut e a fr ame wo rk that prov ide s a sys temic cul tural barri er s [2] .The multip li cit y of lan guages , dialec ts, for hospital s to th ink abou t ho w th ey pr ov ide heal th care an d their elm ing to ho spitals and cul tur es can be overwh tha t is cul tur al ly and li ngui sti cal ly ap pro priate. Hosp ital s, La ngua ge, and Cult ure (HL C) stu dy st af f. The se t ou t to better unde rsta nd how the cha llenges ass oc iated rs are being wit h cultura l and langu age (C& L) barrie AFr amework for Establis hing 1 addr essed at 60 hosp ita ls across the cou nt ry. Pract ices toMeet the Needs of Divers ePop ula tions Exploring Th e go al of this repo rt is to bui ld up on The th ema ti c fram ewor k presente d is de rived fr om cur - Cult ural and Lin guistic Se rvi ces in the Nation’s Hospitals: to provi de ca re th at hospi tal s are empl oying re nt pra cti ces Re port of Fin dings) [3] to pro - A Re port of Fin di ng s (HLC . As th e and se rvi ce s to th eir div er se pati ent popu lations als to de vel op and employ vi de a fram ework for hospit study hos pitals the me s are ba se d on pract ic es th at HLC is no pr ac ti ces for meeti ng div erse pati ent ne eds. There ar e alre ady ca rr ying out, org an izatio ns may find, as th ey “one size fits all” solu tion, and the ro ad map to organi - read th is re port , th at th ey are al rea dy imp le menting so me zati on al cultur al competenc e is un ique for each hospit al. likely of th ese sa me prac ti ces. Addi ti onall y, as hos pitals al l of the answers While th is repo rt does not provide for fac e man y of the sa me cha lle nge s and constr ai nt s in of di ver se pati ent pop ulat io ns, it can meet ing th e needs me eti ng th e ne eds of di ve rs e popul at io ns, th ere may be help org ani zat ions over come some of the challeng es they some can pra cti ce s wit hin ea ch theme that org an iz ations hea lth ca re in an g safe, quality fa ce whe n pr ovidin est ab lis h witho ut allo cat in g substan tia l res ou rce s. increasingly Cha pte r 8: Tai loring ex system. compl Howe ve r, ea ch indi vi dual prac ti ce is no t mean t to be a of Dive rs e Popul ations: In it iat ive s to Meet the Needs A sta nd-a lone sol uti on . A range of prac ti ces span nin g all ns a tool that hospitals Se lf -Ass es sm en t Too l contai and fou r th eme s mus t be ado pte d in a sy ste mic mann er th at can use to pro mot e dis - ot her health care organizations is al ign ed with pati ent nee ds an d orga ni zati ona l efforts cus si on around thei r cur re nt practi ce s and guide res ou rc es . Whil e the pra ct ice s iden tif ied in th is rep ort to addre ss the C& L need s of the pop ulati ons they ser ve. we re im pl eme nted in hosp itals, ma ny of th em ma y be releva nt to oth er health organi zati ons . Meth odo log y Pur po siv e sampl ing wa s used to select the 60 hospit als Esta bli shing a fou n- The me 1: Buildi ng a Fou nd ati on in this stu dy. Da ta were co llect ed du ring one-da y site vis - da ti on of pol ici es and proc edur es th at sy ste micall y support its at each ho spital. Each si te vi si t cons ist ed of a se ries of cu ltu ra l com pe te nce is a cru cial com pon en t of meetin g th e rative red inte rviews with CEO s, administ semi- structu needs of div er se pa ti en t pop ulati ons. Th e role of lead er - s staff , and C&L lea ders , huma an d clinical n res ource shi p is inh er en t to these typ es of act iv ities — leade rsh ip se rv ice s staf f such as chapl ains, interp reter s, and com - su pp or t is requ ir ed to rec ogn iz e, pr io ri tiz e, and oft en drive mana gers. “Prom isi ng” pract ice s were mun ity outreach eff or ts tha t est ab lis h pol ic ies an d pr oc ed ure s to im pr ove ident ifi ed as th ose practi ces that app eare d to be effective care an d to better me et pati ent ne eds. 7 1 For mor e informat io n on the Hos pitals , Languag e, and Culture stud y, in cludi ng the HLC Report of Findings , pleas e visi t www.j ointcommi ss ion.o rg/ Pati ent Safety /HLC.

8 EXEC UT IVE SUMM ARY car e and de cr easing hea lth di spari ti es for partic ula r po pu - In teg ra ti ng C& L co nsid er atio ns in to org anizat ional pol - ns tar - lat ion s in the servi ce co mm uni ty . Ac co mm odatio t- icy an d pro ced ure requi res a demo nstr ati on of commi gete d to the needs of sp ec if ic popu la ti ons evolv e as ment. Witho ut an orga niza tio nal commitment to hos pi tals sea rc h for sol ut ion s to the cha ll en ges of provid ing al comp et ence and subse que nt actio n at the pol icy cultur car e to th eir di verse pati ents . these init iat ives can often be over - and pro cedur e level, shad ow ed by other org aniz ati onal pri or iti es . In or de r to t To ensur e orga ni zations meet ch an gi ng staf f and patien re so lve ch alleng es such as lack of fundi ng and resources ne ed s, the de ve lopm ent of serv ices and ac tiv iti es ta ilor ed for C& L se rvice s, it is imp orta nt for orga niz ati ons to proce ss. for sp ecif ic populati ons should be a conti nuous clar ify th eir comm itment to pr ovi ding culturally com - Whi le the practi ces outli ned in thi s ch ap te r show pos itive of a sup portiv e infrastr pet en t care by cre ating ucture st ep s towa rd th e de li ve ry of cult ural ly an d lin guist ic ally poli cie s and proc edu res that he lp staf f pu t these ideals appropr iat e car e, th ey al so ind icat e the comp lica ted rea l- into action. ity of the lon g road ah ead . Alth ough kn ow ledge, fiel d expe rien ce , and te chn olo gy have im pr ove d th e del iv ery of Theme 2: Collecting and Usin g Da ta to Improve C& L se rvic es, hos pi ta ls ne ed to cons id er th e ba la nce Ser vice s y- and The col le ctio n and us e of communit y. be twe en conve nien ce, cost, pati ent saf ety, and qualit pa tient- level data is ess enti al to de vel op ing and improv - ing ser vices in health care, incl udi ng se rvices developed e 4: Establ is hin g Inte rnal and Exter nal Them to me et the ne ed s of div er se pati ent po pul ati ons. Coll ab or ativ e pr ac tic es en co mp ass th ose Col lab orati on s Ins titu ting pra cti ces to sys te mat ically coll ect data allows th at bri ng tog ethe r multi ple de pa rtme nts, organ izatio ns , of C&L services th e effec tive ne ss and utiliz ation to be pr ov id ers, and ind ividu al s to ac hie ve obj ec ti ves related red, mea sured, monito and eval uate d. Thi s can be useful to cul tur all y and lingu isti cally ap pro priate care . Wit hin can be de si gned to meet th e ng so th at services fo r planni ea ch ho sp ita l, di ff erent stak eho lde rs should be br ough t spe ci fic nee ds of the or gani zati on. to ge th er to de ve lo p, imp le ment, eval uate , and improve ini tia tives aimed at mee ti ng the nee ds of di verse pa tients. hospit col - Wh il e many als acr oss the Un ited Sta tes already s can hel p hos pit al s eng age the ir Exte rnal coll abo ration lect co mmu nit y- and patient-lev el da ta, fe w hos pitals have ity and shar e informati on and re sourc es. co mmun de vel op ed syst ems for using th em to guid e service dev el - opm en t an d im prove ment. A th or oug h und ers tan ding of Coll abor at ion , whet her int ernal or ex terna l, may prov id e the need fo r C& L service s, depend able info rmat io n new av enu es for hos pit al s cur ren tl y und ertak ing cult ural re gard in g the use of tho se serv ic es , an d the usefu ln ess of co mp ete nc e ini ti ati ve s. Th ere is no do ubt that collabo - C& L serv ices can all cont ribu te to th ose dat a to improve ra ti on nee ds to pla y a role in al l th e prac ti ces outlin ed in a ho sp it al’s ab ilit y to id entify and mo nit or health dispar i- thi s re po rt . Buil din g ac tive rel ati on ships with cultura l and y healt h care to cu lt urally ti es an d pr ov ide sa fe , qualit br oke rs, tra di ti ona l heale rs, chap lai ns, relig ious lead er s, . Th e dat a co llect ed may also lin gui st ical ly dive rse patients and othe r indi vi dua ls may enhance an d ext end the hos - nal and lon g-te rm organizatio be used to infor m short- eff or ts services. Wh ile co ll aborative pi ta l’s ex isti ng C&L pla nning C&L -sp eci fic ser vices and pr o- , hel p develop come wi th th eir own challen ges , bu ildin g pa rt ne rs hips gr am s, and id enti fy lim it ation s in staf fin g and resources th at br ing to ge th er th e cham pions of cultur ally and lin - th at coll abo rat ive par tnerships may allev iate. e care has the pot en tia l to mov e th e gu is tic ally appr opriat enti re field forwa rd. The me 3: Ac commod at ing the Ne ed s of Specific 8 g th e nee ds of sp ecific po pu - Pop ula tion s Ac co mmodatin lati ons inc ludes pra ctic es ai me d at pr ovidi ng sa fe , qual ity

9 EXE CU TIVE SUMM ARY Ta ilo ring Initiative stoMe et the Needs of Dive rse Po pulatio ns: ASel f-A sse ssmen tTo ol The self -a sses sment tool can be used to engage members of the orga nizat ion in discussio ns about the needs, re so urces, and goals for providing the high es t qu ality care to every pati ent ser ved. Th e tool is int ended to addres s the main is su es tha t emer ged from th e HLC stud y, and th e questi ons are de signed to promo te discu ssion aro und an or ga niza tio n’s need to improv current e or expand C&L . services The au tho rs hope that this report wil l be a use fu l guide for hospital s and oth er heal th care or gan iza tions to dev el op and impr ove practic es that addres s th e needs of diverse pat ient s. The fram ework present ed in this report can help or gan izat ion s ass es s the ir current pra cti ces and take ac tion to provid e hig h qu ali ty care to the popu lat ion s they serve to ac hie ve opt imal pa tient ou tcomes . in order 9

10 CHAPTE R1: Intr oduct ion the se idea s int o ac tion . Howev er, ea ch in div id ual pra ct ice Ra ci al an d ethn ic he alth dispa rit ies re fle ct po orer hea lth is not mea nt to be a sta nd -a lone so luti on . A ra nge of outc omes an d lowe r qual ity car e. La nguage and cultural d in a pr acti ce s sp anni ng all four th eme s mus t be adopte is sue s can ha ve a sig nific ant im pact on th ese dispa rities sy stem ic man ner th at is ali gne d with th e needs of tion s [1]. As wh en not addre ss ed by hea lth car e or ganiza pa ti ents an d th e re sourc es of the organi zation. are the diver sity of our nation hos pitals con ti nu es to grow, enc ounte rin g more patie nt s wi th cul tur al and language dialects , (C &L ) bar riers [2]. The mult iplic ity of lan guages, Why Is ItImportant toMeet the Needs and cu ltu re s ca n be over wh elm ing to hospit als and their of Diver sePatient s? st aff. The Hosp ita ls, La ngua ge , and Cu ltur e study (HLC) It is wel l re co gni zed tha t co mmu nic atio n is essential to set ou t to bet te r unde rs tan d how the challenges associa ted quali ty car e and patie nt saf ety . Direct co mm un icatio n can barr ier s ar e ad dres sed at 60 hos pi ta ls across the wi th C&L be inh ib it ed by pri ma ry la ng ua ge barri ers, hea rin g or visi on country. Th e fi nd ings demo ns trate that th ere is much impair me nt, li terac y, cultu re, cognit ive limitat ion , int ub a- wor k to be don e to addr ess C&L bar rie rs, pa rtic ular ly in tio n, or di se ase . Indi vidua ls whos e care is inhib it ed due to and consent ser vices, info rmed th e ar eas of lang uag e access a com mu ni ca ti on barri er or a lac k of se ns itivity to a cul - tio n pr ocesses, and the coll ec tio n and re la ted pati ent educa tu ra l belief ma y be at ri sk for poor outc omes [6, 7] . Data us e of pati en t demo gra phic dat a [3 ]. re por ted toThe Jo in t Com mis si on demo ns tr ate th at com - munic at ion is the mo st co mmo n unde rly in g root caus e of Th e he al th car e envi ronm ent of tod ay pre se nts many se nti nel events [8 ]. In addi ti on, a stu dy co nd uct ed by cha ll eng es — fo r hea lth ca re orga nizatio ns, individual et al. (20 04) de ter mined that mis com mun ic at ion Woolf pra ctitio ner s, pati ent s, an d fami li es. He al th care organi - pla ys an importa nt role in me di cine [9]. to me et lega l, reg ula tor y, and za tion s ar e cha ll enged ac cr ed it at ion st an dard s, impr ove heal th care outcomes The financi al bene fi t of prov id ing C&L se rvi ces is di ffi - and sa fet y amo ng the ir pa tie nts, and respect bot tom cu lt to me as ure. Previous stu di es have at te mp ted to qu an - line s. Ind ivi dual prac titi on er s are cha llen ged by time and ra ted an tif y fi na nc ia l ben efi t, but non e hav e demonst restric rest ri ctio ns as wel l as the imp act these fi nancial - und en ia ble retu rn on in ves tme nt [1 0-1 2]. How ev er, if we tions have on thei r abi li ty to pro vi de the bes t care to all un ders tand an d ac cept that effec tiv e commun ic ation is pa ti ent s. La st ly, pat ie nt s and the ir fa milie s fa ce chal lenges inex tr icab ly li nke d to lang ua ge, cult ure, and he al th liter - navigat ing the com ple x he alt h care sy ste m, ask ing the ac y, then it bec om es clear that ad dre ssing these issues rig ht qu estions , and prov idi ng the right inf ormation so pl ay s a si gn ific an t ro le in impr ovin g qu alit y an d saf et y, they can part ic ipa te in the ir he alt h care [4, 5]. resu lting in a posit ive cost -be ne fi t rat io [13] . Ex pl oring upon Th e goa l of thi s rep ort is to build AFramew ork for Est ablis hing Cul tu ral and Li ng uistic Se rv ices in th e Nat ion’s Hosp it als: Pr actices toMeet the Needs of Re por t of Fin di ngs) A Re por t of Fi ndi ngs (HLC to provide Diverse Populat ions for a fr am ewor k fo r deve lop ing and emp lo yi ng practices In or de r to decreas e healt h dis pari ties, hosp ita ls nee d to the need s of di ver se pa tien ts. This rep or t will me eting tak e actio n to und erst and the need s of the ir pati ent po p- ou tli ne a fr am ewo rk of four them es that ref lect con cepts ul atio ns and em pl oy pr ac tice s that hel p add ress those - the auth or s believe cont ri but e to cul tur ally and linguis ne ed s.This re por t pre sent s a fra mew or k fo r orga ni zati ons iate car e. Thi s framewo rk is further dis - ti ca lly ap propr to use when consid er ing the pra ct ices they utiliz e to me et fo r Est abl ishing cus se d in Cha pte r 3: A Fr ame work ed the dive rse nee ds of thei r pa ti ent s. Four themes emerg 10 Pr acti ces to Meet th e Nee ds of Div er se Populat ions. The fr om pr act ices in the HLC dat a. Firs t, we rec og niz e th e depth is the n ex pl ored in greater mea ning of each theme (chap ter 4) of im por ta nc e of bu ildi ng a fo unda tio n in chap ter s 4 throug h 7.Them es ar e ex emp lified by prac - al pol ic ies an d proc ed ures tha t ca n sup por t or ga ni zation ti ces tha t illu stra te how ho spitals are cur rent ly put ting

11 CHA PT ER1: n Intr oductio or gan iz at ion s to work tog et her to evaluat e ne w and exis t- prac tic es to reduc e disp ar itie s in ca re . The second th eme, ing practic es as a mea ns of cont inue d improv emen t. er colle cti ng and us ing data to im prov e se rvi ces (chapt 5) re cogn izes th e im por tance of usi ng data to ident ify On e of the goals of the HLC st ud y has been to pro vide and impr ove care prov ided to nee ds, eval uat e se rvices, th e fiel d with informa tion that is useful and rele vant to ac com modating the di ve rs e patie nts . The third theme, imp rove care for diverse pat ie nt pop ulat io ns. Thi s rep or t (ch apt er 6), states that ne eds of spec if ic po pu latio ns acc ompl is he s this task not only thr oug h sha ring current eff orts to me et dive rse or ganiz ati ons will need to target id eas an d prac tic es from hosp itals tha t parti ci pated in the est ablish nee ds. The fo urth theme invol ve s ing C&L nt too l that HLC st ud y, but by cre at ing a self- ass essme inter nal an d ext ernal (cha pter 7) to iden - coll aborations hos pital s and oth er hea lt h ca re org ani zat ions can use to tify needs , sh ar e resou rces, and wor k toge ther to mee t the he lp th em dev elop, im pl em en t, eval ua te, and imp rov e nee ds of pop ul ations serve d. These fo ur the mes serve as to me et the ir sy stems for ad dress ing the ca re they provide bac kdr op fo r this repo rt and for th e to ol in the st ructural e pa tient s. The se lf- assessm ent to ol is th e nee ds of divers 8: Tail or ing Initiatives Ch apter of to Me et the Needs wit h sug gest ed uses for th e pres ent ed in chapte r 8, along Dive rs e Pop ulati ons: A Self Assessm en t Tool. to ol wit hin org an iza tions. Suppo rt forPr ac tices in th isReport Terminology ed stud ies ev id ence-bas The HLC stu dy di d not conduct thro ugho ut The fol lowi ng two ter ms are used fre quently for th e pr acti ces iden tified in this repo rt , but ma ny of the th is rep ort. Additi onal te rm s ar e de fi ned in th e glos sar y pra ct ic es re fle ct rec omm endations, guide lines, and per - (a ppendi x B). for man ce me as ures fr om other rep orts an d the current lit - of are ma pped to a series er at ur e. As ap pli cabl e, pr actices the abil ity of hea lth ca re pro vi de rs te nce: cu lt ur al compe co nse nsu s- ba se d per fo rma nce ex pe cta tio ns that su pport and orga niz atio ns to unde rst and and res pond effect ively to effect ive comm unic atio n fro m the Et hical Force Pro gra m the cu lt ura l an d lang uage ne ed s brou ght by the pa tie nt to Medica l Association’s report fo und in the American the he alth car e enco unte r. Cu ltura l co mpe te nc e requi res — g Ca re: Ho w Healt h Improvin Imp roving Co mmu nic ation and the ir personnel to: 1) va lue diversi ty; or ganiz ations Ca re Or gan iza tions Can Ensure Effect iv e, Pati ent-Centered 2) as ses s th em se lves; 3) ma nag e th e dyna mi cs of diff eren ce; [1 4]. from Di ver se Po pulations Co mmu ni cation with People 4) acq uir e an d ins ti tuti ona lize cult ural know led ge; and In ad ditio n, pract ice s are mapped to the fed era l Offic e of of indi vidu - 5) adap t to div er sit y and the cul tur al contexts Minor ds for Cu ltu rally and ity He alt h’s Nat ional Standar als and co mmu ni ties se rv ed [1 7]. Care Lin guis tical ly Appro pri ate Servi ces (CL AS) in Health [15] , rec om men da ti ons from the HLC Report of Fi ndi ngs se rvices: cult ur ally and ling ui sti call y ap prop riate [3], and The Joi nt Co mmission’s public pol icy whit e paper hea lth ca re se rvi ce s th at are re spe ctf ul of an d res pons ive to “W ha t Did the Doct or Say? :” Improv in g Health Literacy to cul tur al and langu age ne eds [15]. are Pr otect Pat ient Safe ty [16]. The se sup por tin g refe rences in clu ded th rou ghou t the report. Ho wto Us eth is Repo rt Wh ile th is re port does no t prov ide al l of the an swers fo r mee ting th e nee ds of div erse pat ient pop ulations, it can hel p org aniz ati on s ove rcome some of the ch allen ges they 11 fac e when pr oviding safe , quali ty heal th care in an incr ea s- in gly com ple x sy ste m. The au thors ho pe this report will in spire id eas for addressing di verse ne eds and en cou rag e

12 CHAPTE R2: Met hod ol ogy Ad min ist ra ti ve in ter vie ws consi sted of a sin gle -pers on Th e frame wor k de scrib ed in this repo rt is based on in for- int ervi ew wit h each hospi tal CE O, and leade rshi p, huma n ma ti on col le cted dur ing inte rvi ews with in dividuals work - resou rc es , and C&L ser vi ce s gr ou p inter views , co ns is ting ta l Hospi ing in a variet y of hos pita ls ac ro ss the co untry. of thre e hospital staf f member s fro m eac h area . Pa rti ci pan ts in sa mpling and dat a co ll ect io n me tho ds are discussed were en gag ed in di alo gue s about th e cha lle nge s the ir hos - de tail in tic Serv ic es in th e Ex plo ring Cult ura l and Linguis pit al s face when pro vi di ng care to cult ura lly an d lin gu isti - Nati on’s Hos pit al s: A Repo rt of Finding s (HLC Report of cally di ver se pat ie nt s, how th ey are able to overc om e th os e s) nt s ; the ref ore th ese two me tho dol ogi cal compone Finding cha ll en ges , and wh at they pe rce ive to be th e str engths and [3] . ar e rev isit ed on ly briefly below ally we akne ss es of the ir curr ent syst ems fo r prov iding cultur an d li ng ui stic al ly app ropria te ca re . Th e HL C study wa s appro ved by Th e Jo int Com miss ion Review ct ed ins titutio nal review boa rd, In dep endent contra Cons ult ing , Inc ., an d the in st it ution al review boards of DataAnal ysis sev era l par ti cipat ing hos pit als. The stud y beg an wi th the fo ll ow ing resea rch que stion : Are the re pr om is in g pra ct ic es tha t are he lp ful to and can be re pl ic at ed by othe r hospitals? Two re se arche rs inde pend - Ho sp ita lSamp le en tly id en ti fi ed and cod ed promi sin g pra ctice s in adm in - 32 st ate s partic ip ate d in the HLC from Six ty hos pitals ist rati ve inter vi ew tr ans cri pt s th at app ear ed to be eff ective st ud y. Ha lf of the par tic ipat in g ho spit als (n = 30) were fo r imp rovi ng cul tur al co mpete nce wi th in organ iz ation s sel ected usi ng 199 0 and 20 00 Unit ed Sta tes Cens us an d and /o r dire ctl y meeti ng th e C& L needs of di vers e patie nt l As so ciat io n dat a. Counties Am eri ca n Hospita that sa tis - popu la tion s as re por te d by inte rview pa rti ci pa nts . fi ed spe cifi c size , langu age, nat ivit y, an d racia l and eth nic Qu al ita tiv e res ea rch sof tw are NVI VO 2.0 (QSR ho spitals popu lati on cr it eri a we re rand oml y sel ected; Inte rna ti ona l, Vi cto ria, Au stral ia) was us ed to code an d with in sele cte d coun tie s we re the n recrui ted for stud y par - stu dy was not abl e to sto re tra ns cr ipts . Be cau se th e HLC tici pa ti on . The oth er 30 hos pita ls were ha nd-sel by ected me as ur e or valida te the eff ecti venes s of pra cti ce s dis - the pro je ct te am to en su re tha t hos pita ls mak ing a co n- cu ssed dur ing in ter vi ews, th e res ea rche rs de ve lo pe d an ce rte d effort to add re ss the cult ural and langu age (C&L) inde pende nt se t of cr ite ria to as se ss eac h code d pr ac tic e. ne eds of thei r pa tie nts were in clud ed in the st udy. Thes e Co de d prac ti ce s had to meet at least one of the follo wing hosp ital s wer e ei the r se lf-n omin ated or nominated by a cri te ria to re ma in a promi si ng prac ti ce : memb er of the proje ct team or Tec hnic al Adv isory Panel 1. The pr acti ce is re po rte d to be ne fit the qua li ty or (T AP) who had first -ha nd know ledg e of their effort s. sa fet y of pat ie nt care as evi den ced by at le ast one of the fo ll owi ng: Da taCo lle cti on • Imp rove d pati ent sati sf acti on A one- day si te vi sit was co nd uct ed at eac h partic ipa ting • Reduc ti on in medi cal erro rs /ri sks and March 2006 hospi ta l betwe en Se pte mber 2005 by • Imp rove d sta ff compete nc e research HLC pr oje ct staf f and membe rs of a trained • Imp rove d acce ss to lan guage serv ice s te am. Two indi vidu al s con duct ed each sit e visit (a trained • Faci li ta ti on of th e co ntinuity of car e inte rvi ewer an d a traine d no te- take r), on e of whom was 2. The pra cti ce is rep orte d to re sp ond to a ch alle nge or alwa ys a projec t st aff mem ber . Each si te visit consis ted of nee d in an inn ova ti ve mann er. in tervie ws wit h hospi ta l admi n- ru ctured a seri es of semist 3. The practi ce is re po rte d to im pro ve the hosp ita l’s mar - is tr ati ve sta ff and a separ at e ser ies of int erv iews with floor th e ket po sit ion or fina nc ial statu s wh il e benefiting staf f that ha ve direct pa tie nt cont act on a regular basis. 12 qua lity or safe ty of pati ent care . Th is repo rt ref lects only th e inf ormati on ga thered durin g ist rative ho spit al admin int erv iews.

13 CHA PT ER2: Meth odolo gy The sam e tw o resea rchers join tly rev iewed each practice Tog eth er, these the me s cons ti tute a frame wor k that pro - whe th er it sufficie to de ter mine ntl y me t one or more cri - vi de s bo th an ove ra rc hin g conte xt for each pr actice , an d ied th rou gh this proc ess. teri on ; 163 pr actices were identif a syste mic me th od for hos pita ls to th in k abo ut how th ey pr ovide he al th ca re tha t is cultura lly an d li ngu isti cally Su rv ey of the Members Te ch ni ca l Advis or y Panel app rop ria te. The fo ur the mes are di sc us sed in deta il in 2 co mpl eted a sur vey to cl assi fy each of the pr oj ect’s TAP chapt er s 4 throu gh 7. Due to sp ac e co nstr ain ts an d a 163 pra ctice s as promisin g or no t promis ing bas ed on de si re to emph as iz e the the ma ti c fr amework of th is the cr ite ria used by HLC staff, in additi on to the ir own rep ort rathe r than prac ti ces alo ne , a sub set of the 11 8 pr ofessiona l exp er ti se. Tw enty-fo ur surveys were diss em - pr omi sin g pr acti ce s is pr es en ted. On ly sali ent pr acti ces inat ed; 15 comp lete d surveys were ret urned. Prac ti ce s th at pro ject staf f memb ers beli eve can be re pli cat ed in tha t were ide ntif ie d as pro mis ing by at least 60% of mo st hosp ita ls rega rdle ss of si ze, re sou rce s, and patient n were cons id - eac h questio res pond en ts who an swered pop ul ati on are dis cu ss ed. ered eli gibl e fo r th is rep or t. Af ter ap ply ing th is cr iteri on, 118 practic es (72% of the ori gi na l po ol ) we re id entif ied. Challenges and Limita tions Due to the abunda as nc e of prac ti ces ini ti all y iden tified of Based on the la rge number Dev el opm ent of theme s pro mi si ng, th e lengt h of th e TAP surve y deter red some pro misi ng pr acti ces iden tifie d by th e TA P survey, study TA P mem be rs fro m par ti ci pa ti ng. Sur vey le ngt h ma y of the se d that a deta il ed di scussion pe rs on nel det ermine ly ha ve al so affe ct ed TAP memb ers’ abilit y to th orough prac tic es was not poss ible and thu s the original re search revie w pr acti ce s list ed towar d th e end of the doc ume nt . ap pro priate . Th erefore, que st ion wa s no longer the As a result , pr acti ces nea r the end of the surv ey ma y ha ve res earc h que sti on was modifi ed to: Wh at com mon themes had a sma lle r like li hood of bei ng iden ti fie d as prom isin g The 118 ex ist amo ng the practi ces ident ified as prom isi ng? by TAP me mbe rs du e to th eir place ment in th e surve y for com - ly assessed pro misi ng pra ctic es were sub sequent rathe r tha n th eir co mparati ve me rit. mon the me s an d pa tterns; em er ged four ma jor themes from this anal ys is . Ad dit io nall y, none of th e pra cti ce s de scri bed in th is re po rt wer e measure d, tes ted , or va lid at ed by HLC project sta ff. Incl us ion of a pract ic e in this repo rt does not impl y, no r is it int end ed to imp ly, tha t there is inf erent ial, empi rica l Majo rTheme sfrom th eFra mewo rk ev iden ce of it s effe cti veness. for Estab lis hi ng Prac tice sto Me et the Ne edsof Dive rse Po pul ation s: 1. Bu ilding afoun dation 2. Collecting and usi ng dat ato imp rove se rvi ce s the nee ds ofsp eci fic 3. Acco mmodating pop ulat ions 4. Esta bl ishing inter nal and exte rnal co llabo rati ons 13 2 The TAP consi sts of profe ssion als fro m the health ca re fie ld wi th ex pe rti se in la ngua ge and culture. A lis t of TAP me mbe rs ca n be fou nd on pag e 5.

14 CH APTE R3: A Framewo rk fo r Est abl ishi ng Pra ctic es to Mee t the Nee ds of Di ve rse Popula tions Building aFoundation Ex pl ori ng Cult ur al an d Ling uistic Se rv ices in the Nation’s Orga niz ational pol ici es and procedure s can pr ov id e a sup - Hos pitals: A Rep ort of Fi ndin gs (HLC Repor t of Findin gs) ions . portive ba se for meet ing the ne ed s of div er se populat of si x pr es ente d a res ea rc h fr ame work consisting Esta blish ing a founda tion of pol icies and pr ocedu res tha t do mai ns: lead ers hip, quali ty impr ove ment and data us e, syste mic al ly sup port ef fo rts to meet the div erse ne ed s of language work fo rce, pro visi on of care and pat ie nt safety, pati en ts ca n hel p el ev at e the pr ior ity of the se is sues wit hin serv ice s, an d com mun ity engage me nt. The resear ch t th e org aniz atio n, driv e add iti on al effo rts, an d dra w suppor framew ork was base d upon rec omm end ations and exist - fr om st aff. The role of lea de rsh ip is inher ent to thes e types ks fr om the lit erat ure fo r pro viding culturally ing framewor of acti vit ie s — lead ership supp ort is req uir ed to re cognize, and lingu is ti ca ll y ap prop ria te ca re and wa s us ed to prio ri ti ze , and oft en drive eff ort s that est abl is h polic ies and de vel op the re se arc h prot ocol an d interv iew questio ns for pro cedu res for im pro vin g care to better meet pat ien t ne eds. the HL C stud y. Hos pital s are devel op ing supp or tive in fra stru ctur es for The current re port pr ese nts a framewor k for est ablishin g cul tu ral co mp et ence by incorpo rat ing cu ltura l and la n- pr act ices to me et the nee ds of di ve rse pop ulatio ns. As this gua ge (C& L) con side ra ti on s into missio n, visi on , and k is bas ed up on dat a coll ec ted from the HLC fra mewor ent s; org aniz at ion al pla nni ng; and hos pi tal - val ue statem st udy , it is inh eren tly re lat ed to th e re sear ch fram ework. wi de polici es. These high -l ev el ini tia ti ves are sup por te d Wh ile it addre ss es many of the same issu es as th e resea rch by ass igni ng re spon sib ili ty for C& L ini tiati ve s and in fus - fra mew ork , the fr ame work present ed he re provides a new in g cult ur al co mp ete nce into orga ni zati on al sys te ms suc h per spec tiv e. as recr uitmen t proce sses and bud get sy st ems. C&L con - es si de ra tions are includ ed in pat ient care thr oug h process Thi s th ematic curr en tprac - fra mew ork was de rived fro m the for tr acki ng pat ient need s, pr ov id ing st aff with th e too ls tic es tha t hosp ita ls ar e emp lo yi ng to prov id e care and serv - 3 to ad dre ss thes e nee ds app rop ria tely , dev elo ping proce sse s In com pa rison to ons. ice s to div ers e pat ient po pulati for inc orp or atin g inte rp re te rs into th e con tinu um of care , orks in the lit era tur e — whic h are of ten ex isti ng framew and dev el opi ng syst em s fo r prov idi ng wri tten mater ials in dev el oped to rea ch the idea ls of cult ura lly and linguistically ts. Int eg rat io n of C&L issues in to unde rstand able forma is based app ro pri at e car e — the fra mew ork in this report or ga nizati on al poli cy and proc edu re re qui res a demo n- y imp lementing. pr ac tices tha t hosp ita ls are currentl upon stra ti on of commit ment . Wit hout an or ga ni za tional com - prac - upon current As eac h of the foll owi ng them es is based acti on at mi tmen t to cultur al co mpe te nce an d su bse quent tice s, orga niz atio ns may find that the y are al read y imple - the poli cy and pro ce dura l le vel, the se initi ativ es can ofte n discusse d withi n these me nti ng so me of the pra ctices be over sha dow ed by ot her orga niz at ional prio ri ti es. th eme s. Addi tionally, as hospit als likel y fa ce many of the the needs of sam e ch allen ges an d con st ra in ts in me eting div ers e popul at ion s, th ere may be so me practices with in Collecting and Us ing Dat ato eac h th eme that or ganiz atio ns can es tabl is h wit hout allo - Impr ov eServices subs tan tial res ourc es . To hel p engag e member cating s of The col lec tio n an d us e of com mun ity- and patie nt-le vel he alth care org anizat ion s in disc ussi ons ab out the ne eds, in data is ess enti al to deve lop ing and imp rov ing services re sour ces, and goal s for prov id ing sa fe , qua lity care, chap - he alth car e, inc ludi ng se rvi ce s deve lo ped to meet th e nee ds que st io ns or ganiz ed te r 8 pr esent s a series of self -assessment of diver se patie nt pop ula ti ons. Hosp ita ls are co ll ectin g and by the sa me fo ur them es. ty and pati ent nee ds , revi ewin g data to assess communi 14 moni tor the use of C& L se rvi ces, identi fy are as for expan- 3 The met hods for develo pin g th e HLC re sea rc h fra me wor k ar e outli ne d si on or impr ov em ent of ser vice s, and id ent ify any dis pa ri - in chap ter 3 of the HLC Rep ort of Fin din gs ; the proc es s fo r de ve lop ing tie s in patie nt care . In stitu tin g pr ac tic es to sy st em at ical ly th e th em atic framewo rk pre sen ted in th is rep ort can be found in Ch ap ter 2: Meth odo logy. co llect data allows th e ef fecti ve nes s and utili zati on of C&L

15 CHA PT ER3: rk for Esta tic es to Meet th e Needs of A Framewo bli shi ng Prac Popul ations Diverse So me cen tral ize d pr og ram s have also em erged as a mea ns ser vice s to be mon itored, measure d, and ev al uated . Th is of addre ssi ng the sp ecifi c needs of popul ation s th at may can be use ful fo r planning so tha t servic es can be designed co nsi st of a sign if ica nt perc ent age of patients .The se ty pes need s of the organ ization. to mee t th e specific of progr ams ha ve be en cre at ed large ly in res po nse to div er se cu lt ur al and reli giou s need s. Acc ommoda tions and review de mographic da ta to It is imp ort ant to collect ta rgete d to the needs of spec ific pop ula tion s ev olv e as and patie nt nee ds be fore deter - asses s bo th co mmunity ho sp it als sea rch for so lu ti ons to th e chall enge s of pro - are mos t ap prop riate to mi ning whic h C&L services vidin g car e to thei r div erse pati ent popula tio ns .To ensu re imp lem ent. Addi tionally, it is cr iti cal to tr ack how often tha t or gan iza tio ns co nti nue to me et st aff and pati ent th ese servi ces ar e us ed to be tt er evaluat e an or ganizatio n’s nee ds, the de vel opme nt of servi ces and ac tiv it ies tailor ed of th e se rvice s that may be Some curr ent C&L ser vices. fo r spe ci fi c po pula tions sh ould be a conti nu ous proce ss . moni tored in clude and spir - servi ces , re li gious language di eta ry reque sts th at are it ual car e se rvic es , and special cul tu ral in na ture . To support C&L data co l- ser vices, Es tablishing Internal and External lect ed bef or e, dur ing , and after pro vi si on can be used to Collabor ations ide nt ify are as for service impr ov em ent or expansi on. hos pitals De velop ing par tn er ship s within an d with exter - th e Un ite d State s alread Wh ile many hospi tals across y na l org aniz at io ns ca n prov id e a me an s for un de rta ki ng few hospi tals ha ve dev elo pe d systems co llect such data, pra cti ces wi thi n th e othe r th eme s. Hosp itals are br in g- devel - fo r usi ng th eir demog raphi c data to gui de service in g toge ther div er se st ake ho lde rs , col labo ra ti ng wi th data from different Anal yzing op men t and impr ovement. othe r orga ni zat ion s to share info rm ati on an d res our ce s, an d str atify ing data by var ious factors can help so urces and pool ing exist ing reso ur ce s with oth er or ganizat ion s s stre ngt hen their C&L serv ices an d address or ganization to imp le me nt C&L init iati ve s by cre ati ng new ma te rials dis pa ri ties in ca re fo r diver se patie nts. and servic es. Wi th in each hospit al, dif fer ent sta kehol de rs sh oul d be br oug ht tog et he r to devel op, im pl emen t, ev al - Ac commo dati ng the Need sof uat e, and imp ro ve init ia tives aim ed at meet ing the needs of di ve rse pati ents. Speci fic Po pul ation s ta rg et ed to speci fi c pop - Cul turall y compe ten t initiatives Ext ern al col la bora tio ns wit h oth er hospit als or health care ulat io ns can help red uce dis pari tie s in se rv ice pr ovision org an iza tion s can help hospit als be tte r addr ess ch al leng es ng practi ces to meet th e and care. Ho spi ta ls are developi suc h as lim ite d resourc es and high co sts for devel opin g chall enge s of spe - literacy la ngu ag e, cul tur al, and health and progr am s. Hos pit al s are al so maki ng ne w ma terials cifi c pop ul ati ons wi thi n thei r ser vice co mmunity . As part use of communi ty re so urce s to hel p re cru it and tr ain a of these ini ti ati ves, hospi tals are int egr ati ng the co ncept mo re div erse work fo rce , br id ge cultu ral or religio us barr i- tent care into staf f tr ai ning and edu - of cult urall y compe an d of hospit al services er s, an d raise pa tient aw ar eness cation . Hospita ls are pro viding staff wi th training that ava il ab le publ ic pro gr am s re late d to th e cont in uu m of car e. enc ompas ses a rang e of activi ties fro m sel f-s tudy educa - Re so urce s and progr am s that may be ne fit from collabor a- le ar ning se ssi ons. To ti ona l mate rial s to in teract ive group tio n in clud e sta ff tra ini ng in cult ura l co mpet en ce , lan - that is inclusiv e of all patie nts, cre ate an en viron ment in guag e se rv ice s, sig na ge an d wr itte n mat er ials av ailable hos pital s ha ve modified or alter ed variou s aspects of th eir ts wh o sp ea k mu lt iple lan guage s, an d reso urc es for patien ways hos - phy sica l spa ce, prog rams, and servi ces. Other 15 only encoun te red by th e ho spit al . lang uag es not comm pita ls are better servi ng di vers e pop ulati ons are by offer - ing ser vices that allo w patient s to more easily navigate the hea lth car e system and ed uca ti ng patie nt s to emp ower th em to adv ocate for th ei r own care .

16 CHAPTE R4: Bu ild ing a Foun da tio n Prac ti ces th at help hosp it al s bui ld a fo und atio n for meet - Make the Mission Actionable ing the ne eds of div er se pati ent s incl ude any practices Interv iews with hospi tal staf f reveal ed that it is izati on wh ich are cod ifie d and set as offi - with in an organ vi tal to oper ati onal ize guid ing prin ci ples int o or whi ch are a part of an organiz at ion’s gen - cial processes, ac tion s or proc es ses thr oughout the or gan iza - eral pr act ice s, oper ati ons, and /or cu ltu re. The rol e of tion. Memb ers of theTAP sup po rted this sent i- le ad er sh ip is in herent to the se ty pes of ac tiv ities — le ad - men t wi th suc h commen ts as “Th is cou ld be rt is req ui re d to recog nize, prior it ize, and ers hi p suppo promis ing if ther ewer ereal initiativ es to add ress ofte n dr iv e effor ts th at est abl ish polici es and pr oced ures this, ”an d“In theo ry, this shou ld dri ve al lleader - th at im pro ve car e to bett er meet the needs of di verse pop - shi p behav ior. ” Hospi tal staff co ncurred wi th a fo und at ion of pol icie s and proc e- ul atio ns . Est ab lishing the se idea s, wit h a CEO from a nort hea ste rn e dure s tha t syste mically suppo rt effo rts to meet the divers hos pit al sta tin g, “It ’sone thingto pu tit in ami s- ne eds of pat ients can hel p ele vate the prio rit y of th ese sion and vision statem ent an d plaster it on the n, driv e ad dition is sue s wi thin the or ga nizatio al efforts, wa ll and to sa yweserve al lpeo ple inthe com - and draw supp ort from st aff. mun ity regard les s of eth nici ty or ra ce; it’s another thi ng to act ual ly do it.” Whi le it is an imp orta nt st ep forw ard for hosp itals to express Deve loping aSup porti ve Infrastructure the ir comm itments to cul tur al comp ete nce in for Cul tu ra lCo mpe te nce their organi zat ion ’sguidi ng princi pl es, the mere ete nt care can be A commit me nt to cul tural ly comp st ateme nt isempt ywi tho ut turn ing these words re fle ct ed at the high est lev el by in co rpora ti ng these ideals int o sup port ing act ions, pro ce dures , se rv ices, nal into an organi zat ion ’s gui din g pri nci pl es, organizatio and resources. al -wid e pol ic ies. Th ese ty pes of high- pl an ni ng, an d hospit lev el act ivit ies can he lp ho spital s dev el op a cohesi ve mes sa ge Th edi stinc tion be tween maki ng ast ateme nt and turn ing that stat ement into act ion was qu iteev i- and better g the needs of divers e popu lations abo ut meetin 4 de ntinintervi ew swithho sp italstaff. For ex am - ica te this visi on to staff, pa tien ts , and the public. co mmun ple ,oneCEOfromasouthern hospital me ntione d ified by ho spital s in the stu dy sample, As exempl a num ber the importanc eof thei rmi ssion st ate ment to the of differ ent op po rtu nitie s exis t fo r inco rpora ting cultur al pr ov isi onof cu ltur aland lang uage (C&L )se rvices , ce in to syste m-w ide practic co mpeten e. notin g,“Wecall it ourco mm unitybenefit stra teg y. In the earl y ’90s we creat ed a new mi ssion — It Start s with As a hospita l’s poli cies, proce - a Mi ss io n prov ide heal th and medical services to meet [the dur es, an d ove ra ll pr act ice are often driven by it s miss ion, needs ]ofthe communi ty we serve. Itisbas ed on at io ns ma y want to inc orpor ate a visio n, or val ues, organiz a strat egy of improv ing he alt h status . . . . The commi comp tm ent to cultural et ence in these guiding board pus hed the hospit al toreally livethe mi s- pr inci ples , es pe cia ll y in th e miss ion stat ement . Revie w of sion /vision. ” Although this part icul ar hospi tal’ s the miss io n sta te men ts of th e 60 st udy ho spita ls revealed miss ion stateme nt does not inc lude langua ge ref erri ng di rec tly to cult ural compete nce, they 4 Lit eratur e in the fie ld ha s sup po rte d the development iz a- of an organ tiona l infrastruc tur e to se rve as the fou nda tion for and rei nforc e initia - ha veoperatio naliz ed their missionof “meet[i ng] . As tiv es th at help bett er meet the ne eds of di vers e patient popul ations the needs of the communi ty [the y] serve ” int o tions shoul d devel op, me ntio n, “He alth car e organiza the CLAS standards implem ent, and pro mo te a wri tten str ategic pla n tha t outlines cl ear go al s, ac tions that inc lude the impl ement atio nofC&L ility/ overs ight accountab pla ns , and man age ment polic ies, op erational se rvic es. Asthi sho sp italexe mp lifies, statem ent s mech anisms to pro vide cultu rally and li nguistica lly appropriate ser vices” 16 8). In additi on to havi ng this infras tructure in pl ace, (CL AS Standard of com mi tmenttome eting the needs of diver se rec om men ds, “Hospita as the HLC Re port of Finding s and l CEOs po pu lat ion sin an organ iza tion’s guiding pr inciple s al ly ot her hospital leade rs shou ld mak e the ir commitment to cultur mus tgohandinha nd wi th opera tional izing those app ro pri ate ca re highly vis ible to hospital sta ff and and li ng uistically Impr oving Commu pa tients” (Reco mmen da ti on 1-2). Sim ilarly, nic ati on co mmi tme nt sint osupport ing hospit al prac tices. — Impro ving Care advis es that “the wo rk for ce [be] know ledgeabl e about lea dersh ip commitm en t” (Co nte nt Are a 1, Performa nce Expecta tio n 6.1).

17 CHA PT ER4: Building a Fou ndatio n refer - that onl y on e hosp ital, lo ca ted in th e west , directly HL C resea rc h fram ew ork fro m Ex ploring Cu ltu ra l and ce. cult ural co mpeten other en ced the term hos - Alt hough Lingu is tic Se rv ic es in the Nat io n’s Hospit als: A Repor t of in cul tural competence mention pita ls di d not directly [3], and perfo rma nce Fin din gs (HLC Repor t of Find ing s) many their missi on stat ements, had visio n or valu e st at e- Impr oving ex pect ation s fro m AM A’ s Ethi ca l Force repor t tha t refe rre d to “vul nera ble popu lations ,” “un der - ments cat ion — Imp ro ving Care: How Health Ca re Communi popul ,” “di verse served po pul ations at io ns,” or “d iverse Or ganiza tions Can Ensu re Effe ctiv e, Patie nt-c ente red nee ds .” Ho spit als seem a va riety of terms to to be using Com mun icat ion wi th Pe opl e fr om Di vers e Po pul ati ons [14] . refer to th eir comm it ment of div ers e to meet ing the needs com - popu la tions. Whil e it can be argued that a verbal al Com petence Po licie s Dev elop in g Polic ies fo r Cultur of “v uln er able” or “div erse” mit ment to servi ng the needs e the of fer an addi ti ona l vehi cle to clearl y communicat ng “cu lturally popul ation s is not eq uiva lent to providi co m- e and org ani zat io n’s comm itme nt to cultu ral competenc 7 The stu dy findi ngs sug ge st th at pe tent car e,” it is imp ort ant to reco gn ize that hos pita ls are equ ita bl e ca re to sta ff. man y sta ff ar e no t aware of ways to me et the needs of mak ing str id es by in cluding com petenc e iss ues at cultural dive rse pa ti ents and ar e so metime s no t aw are tha t it is in their hi gh ad mi nis trat iv e levels and ment io ning them izati onal polic ies art ic - part of thei r re sp on si bi li ty. Organ or gani za tio n’s mis si on, vision, ts . or va lu es statemen ula te to sta ff the “d os ” an d “don ’ts,” bu t are limit ed in their abi lit y to pr ovi de guidan ce be yond th at. Des pit e ationa l a Par t of Organiz Mak ing Cultu ra l Competence th es e limi tati ons , poli cies can help ensu re th at staf f re c- into cultu ra l competence Hos pit als can integrate Pl anni ng og ni ze the im por ta nce of cul tur ally an d li ngu is ti ca ll y their or ga niz ati onal planni ng. As hospita ls in the HLC appr opr iate car e to th e or gani zati on an d to patien t car e into ra ted, one way to integ rat e these needs stu dy demonst as we ll as th eir role in up holdi ng tho se id eal s. org ani za tion al pl ann ing is to use the Of fice of Minority an d ally He al th’s Na tio nal St andards for Cultur (CLA S) in Healt h Care iate Services Li ng uist ic ally Appropr 5 On eTAP mem - care [15 ]. as a blu epr int to gu ide equ itable be r share d fr om pers onal ex peri ence, “This pr acti ce has “We do n’tsa y[us ing CLA Ssta nda rdsto de. [We have] for us program-wi used yi eld ed good results gui de plan ningis] the be- all, end-all. Wh at CLA S as a veh icle to achieve a nation al dive rsity agenda and weare say ing,ho wev er, is that con sis tent “ organ izat io na l missi on.” While th e CL AS standa rd s are nei - wi ththesys tem’s go al to pr ovide an ther exh austi ve nor pr escrip tive in how or ga niza tions shoul d equ itabl eex perience ,[CLA S] is abluep rint care, they pro vide cul tu ra lly and lingui stica lly appr opriate that hel psuskn owwh atto target, wha tto pre se nt a sta rting po int or a genera k, out lining l framewor foc us on .We wouldn ’t kn ow [othe rwise]. di sti nct ar ea s in whi ch hosp it als should have sy stem s or We [would]kn ow bywh atpeo ple tell us proc esses in place to add ress patient ne eds. about their exp er ien ce s, but we wou ldn ’t hav eamo reformaliz ed ap proach for an d framew Hos pital s can use other standards orks from doi ng it ifweha dn’ tfou ndthestan da rds .” Oth er th e lite ratur e to guide organizati onal planning. –C EO from a 6 on’s standards, re sou rces in cl ude The Joi nt Commissi th e no rthe aste rn hospit al onal plann ing is an impo r- g cultu ral comp etenc e int o or ganizati 5 Int egratin Improv . ing tan t step tow ard me eting the need s of div er se pat ien t popu lations ” advises Com mu nica tion — Improv ing Care , for ex ample, that “the orga niza - 17 an d ope rat ional pl ans addres tion ’s wri tten str ategic s iden ti fyin g an d appro - 7 The rol e of or gani zati onal pol icies tha t su ppor t cultur al com petence g the co mm unicat ion ne eds of com mun ication -vu ln erab le pri atel y meetin ic ati on — Imp rovi ng Commun has be en recogni ze d in the lite ratur e. pop ul ati on s” (Co nten t Area 1, Per fo rm ance Expec tatio n 1.0). sugge sts tha t “the or gani zation Imp ro vi ng Care has polic ies that ad dress th e com mun ic ati on ne eds of com muni catio n-vul nera ble popul ations standards have be en mapp ed to the CLAS 6 The Joi nt Commission’s and that place the se ne eds in the co nte xt of oth er or gan izatio nal need s avai la ble at www.joi Stan dar ds in a document ntco mm iss ion .org/ and pr ior iti es” (Conte nt Are a 1, Pe rfo rm ance Expectatio n 4.0). . Pati entS afe ty/HLC/

18 ding Buil CHA PTE R4: a Fo undat ion Se vera l HLC zatio na l study hospital s ment ioned that organi Wha tis aPr ofessional Healt h cult ural se nsiti vi ty in the pro visio n of care. po li ci es reinforce Car eInt erpret er ? In so me ca ses, this in cl ud ed puni tiv e meas ur es th at would ”ref erred to wi thin this report are The “interpreters , such as remova l of sta ff or be ta ken if viola ti ons occurred co ns ide redprof essi onal ,trained,and ev al ua ted ma nda to ry facil it at ion of a peer dis cus sio n group on cul - int er preters,notsimp lybilingualindivid ua ls. Th e 8 a definitive Whil e pol ic ies may provide tural sens iti vity . Na tiona lCounc ilon Inter preting in Health Car e me ans of ad dr essi ng the need s of diverse patients, they are defi nesapr ofessionalhea lthca reinte rprete ras no t a sub stit ut e for educa tio n or a means for monitoring “anindivid ua lwith appr op riate trainin gand expe - nce com pli anc e. Staff s and cul tu ral co mpete awarenes rie ncewh ois able tointerpret with consistency and acc uracy andwhoadhe restoaco de ofpro- sh ould be built up on a sh ar ed des ir e to understand and fess ion alethics” [18].Int erpreter scanbe on-site me et the need s of pati ents, ra ther tha n a me ans of avoi ding int er pret ers;inter pr etin gse rvice scou ld also be pun ish ment. prov ide dvi atel ephone orvideo. l poli - In add itio n to gen eral staff beh av ior, org aniz ationa cies can lend supp or t for ho sp ital pro ced ur es such as the Su staini ng a Dive rse Work Re cr ui tin g and forc e us e of pr of essio na l health care inte rp ret er s. Se veral of th e Ho sp it al s can pri orit iz e di ver sit y wit hi n recrui tment and mentio ho spit al s in the study ned th at their organ ization s hi ri ng proce sse s in order to inc orp orate cult ural compe - 9 refra in fro m the use of fa mil y, mi no rs, or oth er untr ained te nce co ns ide ra ti ons at the wo rk for ce le vel. So me hos- ind iv idu als as inte rpr eter s, al though staff int er views pita ls repo rted ef for ts to inc re as e th e eth ni c and/o r face challen ges when han - rev ea led th at man y of them lan gu age co nc or da nce between th eir st aff and patie nt dlin g sit uat ion s in which pat ients bri ng a family member po pul ati on. As a human re sour ce s staff member from a o- or fr iend and pre fer this in div id ual over th e ho spital-pr mid weste rn hos pit al stated , “We advert ise in local nei gh - al poli ci es may pl ay a significant vide d interp ret er. Hospit bo rho od papers fo r certai n pos iti ons , and par ticipate in ng such chall enge s by co mmu nicating to role in addressi jo b fa ir s. The re is on e [job fa ir] fo cu se d on La ti nos . this ty pe st af f a clea r, uni versa l proce dure for nav ig ating Nur se recru itme nt is a bi g issu e eve rywh er e — bilingual be of sit uation . Any orga niza ti ona l pol icies should nur se s get the red carp et tr eatm ent.” (s ee Chapt er 6: accompa nie d by staff tr aining . Accom moda ting th e Needs of Speci fi c Populations) Onc e ho sp it als re cr ui t a dive rsi fied staff, th ey mus t als o 10 whic h cons ide r ho w th ey will mainta in th eir wor kfo rce, es ter n hos pital pre se nt s its own set of chal lenges . A midw Integr atin gCu ltu re and Lang uage trans fo rme d its obs te tr ics wo rkf or ce fro m a br anc h con - int oOrga ni za tio na lSyste ms sist ing entir ely of male do ctor s to a bil ing ual depar tmen t Incor porat ing the ideals of cultur al compe tence into with more female than male ph ys ic ian s over the course of is a plann ing process es, guidi ng pri nci ples , and policies th eir se ve n ye ars . Thi s pract ice subse qu en tly in creased st ron g starting po int for cul tur al co mpe te nce; the infu - noted, pa ti en t pop ula ti on. As the CEO of the hospital sio n of the se prin cipl es int o org ani zat iona l system s is th e next lo gi cal st ep. For th e pur pose s of th is report, organi - 9 Pr act ice s th at he lp or gani zati ons dive rsi fy staff th rough their recru itmen t zation s pr oc es ses that are at a higher al sys tems encompas and hi rin g proc es ses is ad dr ess ed by CLAS Stan dar d 2: “Heal th ca re le vel in the organi zation tha n the di rect deliver y of or gani za tio ns shoul d im pl eme nt strate gi es to rec ruit, retain , and pr omo te at al l level s of th e organ iz ati on a di ve rs e staff an d leade rsh ip th at ar e pa tient ca re. re pre sent ati ve of th e demogr ap hi c char acter istics of th e ser vice ar ea.” 18 8 Havin on respe ct or cu ltu ra l g sp ecif ic act ions tied to th e vio lat ion of policies a diver sifie d staf f, 10 To he lp fo rm ali ze proce sses ar ou nd maintaining Car e, n — Im proving Impr ov in g Com municatio sen sitivi ty is suppo rt ed by nication — Improv sugges ts th at th e or ga niza - Impr ovin g Commu in g Ca re l for iden tif yin g whi ch rec omm end s th at “t he or gan izat ion has a protoco for ma inta in- tion have “a wri tte n pla n tha t in cl ude s goal s and policies and respo nd ing to members of it s workf orce who com mu nic ate with in di - s it ser ves — ing a wor kfo rc e th at me ets the ne eds of th e po pu lation vid uals in ways that lack respe ct, comp assion or soc io-cu lt ura l sen sitiv ity” lne rabl e popul ation s” (Con tent Area 4, icati on-vu esp eci al ly its commun (Con tent Ar ea 5a, Per fo rm ance Ex pect atio n 4.0). Pe rfo rmanc e Exp ectati on s 1.0).

19 CHA PT ER4: n a Fou ndatio Building The pra ctic e sugge ste d her e is to ha ve a task fo rce that fr om mo st other hospit al s. “The envir on men t is different op era te s at a , wh ich mea ns ta king resp on sibil ity hi gh level The re is a hosp ita lit y fo cus. [Th is hosp it al’ s st aff] ne eds to for and dri vin g in iti ati ve s aro un d cul tura l com pe te nce . As al dem ands; therefore, dea l with pat ien ts [an d] their cultur C&L se rv ic e sta ff from a mid we st er n hos pi tal sa id , “When rics].” peop le ch oose this ho spital for its ap pro ach to [obstet we star te d a sma ll com mi tte e, we only ha d a co re gro up of de dica te d pe opl e. The n, [f ro m] 1995 to 1996, [th e hos pi - with ou t Recr ui tin g a di ve rs ifi ed work fo rce do es no t come d ta l] dec ide d to rev is e the de li ver y of care with manage for un dert akin g the se types cha llenges. A la ck of resources car e [an d] re ali ze d th at pro fi ta bilit y was rel ate d to pro vid - of re cruitme nt effo rts was cited by hos pita ls as one of the in g C&L ser vic e. The committe e be came mor e of a str at e- it ive environment maj or cha ll en ge s they fa ce. The compet gic te am . . . . No ho sp ital ca n do an ade quat e job un les s it of recr uitme nt can pose addit ion al ch allenges for sust ain - a high -quali ty ta sk fo rce group . A co mmit tee fo rm ulates in g a di ve rse workf orce. As th e aforem said, en ti on ed CEO ju st can ’t do it , but on ce we wer e at the syst em -wi de tas k “Ot her ho sp ital s are stea ling the st aff [we hav e] tra ined.” forc e le ve l, we were able to get ‘clo ut ’.” As th is exa mple show s, creati ng a task for ce tha t has the po we r to inf luence hospi ta ls ar e re solving th e issue of sustai ning a diver se Some pl ann in g and org an ization al -l eve l cha ng e is a sub st anti al financial rce by prov iding workfo inc entives . A member of underta king tha t requ ir es th e ac tiv e parti ci patio n of a lea de rs hip from a western hospi tal no te d, “We have pu t num ber of stake ho ld ers from thro ug ho ut the or ga ni zatio n, who are posi tion s so that on ly people wa ivers on some includi ng lea der ship . Inv olv ing hig h-l evel manag ers an d bi lingu al can be hir ed fo r that po sitio n. We als o pay our or gan iza tio na l dec isi on ma ke rs may help move initiative s staff to int er pr et. It [pro vid es] incentives [fo r] staff to work for ward. While the hosp it al in thi s exam pl e is part of a sys - on the se sk il ls so that the y can get ad dit ional pay.” It is tem, the high-l eve l task force can be im plem en ted in ind e- im por tan t to keep in mind that any staff used to in te rpret pe ndent org an izat ions .The im po rtan t pie ce of th is practi ce la ngua ge sh ould be tra ined and assessed in bo th the target is as sem blin g a grou p tha t will le ad and ta ke res po ns ibility an d Eng lish. Hosp it al s can provi de in ce ntives for st af f fo r meet ing the need s of dive rs e pati ents . Th is may hel p na l or who bec ome professio me mber s wh o are cu rrently st re aml ine act iv itie s and dri ve out co me s. Ide ally , th is hi gh- on ed th at they ar e not in te rpr et ers. Som e hospi ta ls menti level ta sk forc e wo uld co nsi st of a multi di sc ipli na ry gro up su re how to st art recruiting mo re divers e staff. As hospi ta ls r 7: of mem ber s with di ve rs e ba ck gro un ds (se e Chapte tr y to addr ess th ese ch all enges, ethnic so me have tar geted Esta bl is hin g Intern al and Ext er na l Co ll ab ora ti on s). on med ia ou tlets to ai d the ir recruitme nt eff orts. Co llaborati uni ty org aniz ations wit h oth er enti ti es such as comm or St ruct urin g Supp ort ive Bu dg et Sy stem s for Cult urall y acade mic insti tu tions may pro vid e add iti onal reso urces Ano ther cruc ial and Linguis tica ll y Ap pro pria te Ca re and oppo rtun it ies (see Chapter 7: Est abli shi ng Inte rnal and ele me nt needed to suppo rt cul tural com pet ence wit hi n Ext er nal Colla bo ra tio ns). an org ani zati on is th e es tabli shme nt of in tern al bud get t cult ura lly and lin gui st ica lly ap pro - sy st ems that suppor Force Hosp itals fe lt it was ing a Hig h-L evel Task Creat 12 priate car e. imp orta nt to est abl is h a hig h- level ta sk force to drive in i- Thi s is esp eci ally impor tant giv en that the issu es tia tive s an d take res pon sibi lit y for dive rsi ty-related ma jo ri ty of HLC study hospi tals — ninety per ce nt — 11 wit hin th e organ izati on. Whi le hav in g any orga ni za - me ntio ned a lack of fu ndi ng as a challen ge for C&L ser v- driving its div ersity initiatives tional com mit tee or entity wo uld giv e C& L serv ices the ic es. Whe n ask ed what lead - tte e’s re cogni ti on by hospital is val uabl e, the commi ly sta ted “more gr eates t boos t, resp ond ent s over whelming wit hin in ef fe cti ng change ers hi p is key to its influence mone y” or “r eimb urse ment for int er pr eter serv ices. ” Some 19 the hos pita l. of the se fin ancial cha ll en ges can be ove rcome throug h 11 Impr ovi ng Com municati on — Imp rov ing Care sta tes, “A t least one 12 Budg et sys tems that pr omo te the us e of language se rvi ce s is sup po rte d a foc us on addr ess ing in divi dual or commi tte e ha s as on e of its charges by the : “Fi nan ci al ince nti ves shoul d be cr ea ted HL C Rep ort of Fin di ng s rable pop ulatio the sp eci fic ne eds of comm unic atio n-vulne ns” (Co nte nt to pr omo te, dev elo p, an d mai ntai n ac ce ssibil ity to qual ifie d health care Area 1, Pe rformance Expe ctati on 5.1). int erpreters” (Rec omme nd atio n 1-4).

20 ding ion a Fo undat Buil CHA PTE R4: Th is in for mat ion may in cl ud e the pat ien t’ s ag e, gender , exter nal fun ding ing reimbur sou rce s, includ sement ra ce /et hnic it y, pr ima ry spok en an d/or wr it ten lang uag e, thr oug h Me dic aid and St at e Ch il dre n’s Health Ins urance reli gion, sexu al or ien tat ion, dis abil it ies , cult ura l needs, P) pro gram s, joi nt col laborati Pr ogr am (SCHI ons , and 13 die ta ry nee ds, and hea lt h lite ra cy leve l. The data can serve gr ant fu ndi ng. mu ltip le purp os es an d wi ll he lp in form sta ff of the pat ien t’s the hea lt h ca re comm unic at ion nee ds thr oughout Wh il e the se so urces may add re ss fund ing issues ov erall, enco unte r. Ad ditiona lly, on the agg reg at e level , these meas - ant to ex ami ne the inter na l budget it is equ all y import ure s may se rve as one way for ho sp ita ls to tr ac k dem an d for syste ms, wh ich ma y inadv ert ent ly creat e barriers. While langua ge serv ices , suc h as in ter pr et er s or oth er la ngu ag e th ere is no ide al uni ver sal budg et syst em for the pro vision ac ces s ser vic es (see Chap ter 5: Col lec ti ng and Using Dat a to hospi tal s are findi ng diff erent ways of lang ua ge ser vices, Im pr ove Se rv ice s) . Hosp it al s ut il iz ed a wid e ra nge of tra ck - to rem ove such fi na ncial bar ri ers. One midwestern hos - ing sys tem s, suc h as the use of st ic ker s or ot her fla gg ing so pital has centr ali zed its bud get for int erpreter services dev ices in the cha rt ind icat ing th e need for langua ge se rv - budg et ed th at the us e of inter preter se rvi ce s is no longer ices; dir ect docume nta tion in the patient rec or d; a pa tie nt and cha rged to ind ividu al dep artments. Although this summary fa ce she et incl ud ing cat egor ies for lan gua ge bar - was a rela tively new pr act ice at thi s hosp ital at th e time rie rs, ph ysical constr aint s, etc.; and col or- cod ed armb ands of th e stu dy , its results serv ice were pr omi si ng. A C&L ge s spo ken by a pa tie nt . that ide ntif y the diff er ent langua ed, “[I t is] amaz ing how [the cen - st af f mem ber remark the resi sta nce to usi ng inter - tra li za tion ] has changed While a wid e var iet y of trac kin g system s ex ist, th e nee d for pre ters.” As bud ge t systems ma y crea te a considerable un t. One co nsi stenc y in usi ng th ese syste ms is paramo dis incenti ve to uti li zing C&L servi ces , hospi tals sh ould est ern ho spit al me mb er of C& L ser vic es from a midw cons id er how the se fund ame ntal sy st em s may imp act the no te d tha t althou gh thei r el ect ronic reco rd syste m incl ude s s th ey prov ide. Staff shou ld not be inhibited service to use a cha lleng e needs, ’s C&L a fi eld fo r re cordi ng a patient C&L servi ces to meet pati ent ne eds. Ev en if budgets for they con tin ua lly fac e is th at the fi eld is not man dato ry. the se serv ice s are not cen tr aliz ed, mo ni tori ng pati ent Des pi te th e fact th at thi s hospita l has ma de notable effo rts need s an d util izat ion of C&L serv ice s (s ee Chapter 5: to esta blish a pro ces s for iden tif yin g pa tien t nee ds, it is Colle ctin g and Us ing Data to Im prov e Serv ices) ma y un cle ar how ef fect ive th es e sys te ms wi ll be with out con sis - help or gani za tions evalu ate the eff ectiv eness of their cur - tent doc ume ntati on . Addi ti on ally, altho ugh the init ial re nt sy stems or pro cesses. Integr atin gCu ltu ral Co mp etence int oPati ent Care “We are tryin gtoca pt ure cu l- Ch an ges in pat ien t care ar e nec essa ry to co mplement [int erpre tat ionse rvices] inone tu ra l comp et en ce at th e org aniz at io nal pla nning and sys - cent ral bud get —tryin gnot to put Th ese practic es incl ude any pr ocesses th at tem s levels. “ dep artme nts in theposit ion that they ho spi tal s us e to id en tify pat ient s’ div er se needs , to matc h avoi dcal ling languag elinebecause the se nee ds to ap pr op riate ser vices, and to effectively com - itwil lcome out ofthe irbudge t. Now it muni cate wi th pa tie nts thr ou gh out the pro visio n of care. come sou tof the Guest Servi ces bud get ...w edon ’twa nt pe ople to be Trac king Pat ient Ne eds One im portan t component of car - reti cen tbecause ofthe bud get. ” po pulatio ns is pro vi di ng sta ff with th e nec - ing for diverse 20 –A me mber of leadersh ipfrom needs. essa ry too ls to easil y collect inf ormat io n on patient ami dwest ern hosp ital 13 To provid e health ca re orga ni zati on s wit h mor e inf ormation on reim - bu rs ement Heal th La w models , the Ac ce ss Pro je ct and the National e availabl Actio n Kit, Langua ge Services Pro gr am (NH eLP) re lea se d the ” ac tio n_kit.pdf. vices_ je ct.o rg/ ado be/ lan gu age_ser at www. ac cesspro

21 CHA PT ER4: Building a Fou ndatio n In cor po ra ti ng Int erpre ters in to Pat ie nt Care As ma ny ide nt ific ati on of pat ien t needs is imp or tan t, orga ni zat ions of th e hos pita ls sha re d, int erp re te rs can fac ili ta te patie nt- needs shoul d keep in mind tha t all of a pati ent ’s C&L may of pro vid er commun icati on thro ugh out the continuum not ha ve been captu red in th at firs t as ses sment. Patient 15 car e. Fo r exa mp le , in addi tio n to pro vi ding se rvi ce s dur - nee ds shou ld su bseq uently be docu me nte d over time as er, hospit al s ut ilized in ter - rovi der encount ing the patient-p th ey are ident ified in order to pr ov ide both ef fecti ve hand- prete rs th ro ugho ut a patie nt ’s vis it, from the admis sio n at ion . off and pa tien t- pr ov id er com munic pro ces s to ex plain ing th eir rig hts an d th rou gh the dura tion of lab or at or y tests . ri at e Language Services As with mini ng Approp Deter needs , hosp itals de vel oped a syst ems for tr ac king patient Int erpr eter s ca n be use d to facil ita te pre-v isit sche dulin g to tree s and charts decision var iet y of too ls, including and logist ics. On e no rt hea ste rn hosp it al, for ex amp le, help gu id e staf f th ro ugh the dec isio n pro cess of sel ecting a pa rtne rshi p bet ween thei r Int erp reter de vel oped iate langu ap propr es an d prese nt infor mation age servic 14 Th ese tool s give hos pital s De par tm ent an d doct ors’ offi ces withi n the area. To strea m- fo r access ing th ose services. an add ition al opp ortunity to communi cate to sta ff any lin e this pro cess , int erp rete rs woul d sche dule and att end reg ardi ng C&L-specific rela ted policie s or procedures visi ts with the pati ent as well as ca ll bef ore ou tpa tien t vis - procedures ti ng these se rv ices. By cl ea rly communica its to en su re tha t pa ti ents kne w wh ere to go . Uti liz ing inte r- hospi tal s and giv ing dec ision -ma king to ols to staff, pret ers to hel p with sch edu li ng an d lo gi stics in thi s way can can increas e the likelih ood th at sta ff wil l access the hel p all evia te nav igati ona l bur de ns and po te ntia lly reduc e cons istent ly. ap prop riat e service s more the nu mbe r of no-show s fo r off ice vi si ts. These to ol s are meant to compl eme nt and reinforce — Wh ile th e pra ct ice s dis - Tr ans la ting Wri tt en Mate rial s no t replace on, edu cat io n, and — other communicati cu sse d so far hav e prima ril y rev olve d ar ound ora l co mmu - le, one of the cha lleng es men - . For examp tr ain ing ac tivities and the use of inte rp ret er serv ice s, C&L ni cation p is th at staff may not be us ing ti oned by hosp ital leadershi co nsi derat ion s ar e ap pl ica ble to all po ints of commun ic a- 16 the teleph on e int erp re ter serv ice as muc h as they sh ould. ing any pri nt ed ma teria ls . ti on with patien ts, includ of prin ted pat ient mater ials that hos pitals Ex amples may Whi le sta ff may not be awar e of th is serv ic e or the appro - ne ed to prov ide in mu lti ple langua ges or in pla in la nguage it s sit uat ions in whi ch hosp ita l pro ced ur e di ctates priate inc lu de inf ormed al s, educa tiona l materi forms, consent al s shou ld not over loo k ot her factor s tha t may use, hospit wri tten inst ru ct io ns, na vi gati ona l signa ge , and medi cation co ntri but e to the prob lem. In this ca se, the low rate of tele - in for ma tion. HL C stud y hospi tal s de veloped syst em s fo r ph one ser vi ce use may be link ed to the st aff’ s perceptio n envi - or ease of us e of the tel ephone serv ice, cost issues, prov iding me dicat ion info rma tion and pre scri ption la bels equ ipment. In order ron menta to l bar ri ers , or low-quality in a patie nt’ s prim ary lan gu ag e. Hos pi ta ls may al so con - add ress su ch challe nge s, hospitals sh oul d co mmun icate si der usi ng symb ols to brid ge barrie rs pre sente d by hea lth di rectly pro - wi th st aff an d prov ide too ls tha t streamline lite racy . A we st er n hosp ita l, for exa mpl e, us ed symb ols on ce du res. One appro ach in thi s exam ple would be to collect te instr uctio ns for ta king me dic at ion lab els to co mmunica da ta on the ut ili zati on of tele phon e servic es and in-person medic to pati ents. Ho sp ita ls sh ould kee p in mi nd ations in terp reter s as wel l as the costs asso ciat ed with those serv - 15 Joi nt Comm is sio n sta ndar ds re qui re that or gani zati ons provi de “i nte r- e ice s (s ee Chap ter 5: Collectin g and Usin g Data to Improv pr eta ti on (in clud ing trans lation ) se rvi ce s as nec es sary.” In ad di tio n, as Se rv ices) . The se da ta can then be co upled with feedbac k HL C Rep ort of Fi nd in gs, re com me nde d in the “Hea lth care inter pre ter s uni cati on duri ng al l info rme d cons ent sh oul d be us ed to faci li tate comm ec ific ser vic e issu es. from st aff to re co nc il e an y C&L-sp 21 pr oce sses in vo lv ing patie nts wi th lim ite d Engl is h profi ci enc y, and cul tural brok ers shoul d be us ed as a res ou rce when a pati ent’s cul tural riate servic es n on acc es si ng approp 14 Pro vid ing st aff with informatio en dati on 4-2). bel iefs imp act car e” (R ecomm ication is add res se d by Impro vi ng Commun — Imp rov ing Care , “Th e 16 Joi nt Comm is sio n sta ndar ds re qui re that “w ri tte n info rmati on provi de d , or has access workforce knows ou tlin in g, the prim ary to in form ation is ap prop ri at e to the age , und er stan di ng, and , as app ro pr iate to th e cont act person or office for interp retatio n se rvi ce s, work force deve lo p- po pu lat ion serv ed, the langu age of the patie nt.” men t, communicat ion trainin g and oth er releva nt com mun ic atio n issu es ” (Cont ent Area 1, Perform anc e Expec ta tion 6.2).

22 CHA PTE R4: Buil ding a Fo undat ion Conclu sions s th at ar e tra ns lated should tha t any wri tten material be eval - Bui lding an infr ast ruc tur e by devel opin g hospit al polic ies th at the intend ed infor mation is uate d in ord er to ensure cul tu ral com peten ce is a cru - and proc edu res that support acc ura tely conve ye d. ci al comp one nt of meeti ng the needs of divers e pa tien t Int eg ra ting C&L con sid era ti ons into org a- po pu lations. Ho spi tals are ma kin g stri de s in providing wri tten ma teri - ni zati onal poli cy and pro cedu re req uir es a dem on str ati on als in multi pl e la ngua ges. De sp ite these suc cesses , hos pi- of com mitme nt . Wit ho ut an or gan izat iona l comm itm ent tal s co nti nu e to strug gle to provi de mat er ials in lan gua ge s ent act io n at the pol - et ence and su bsequ to cul tu ral comp the y enc oun te r le ss frequentl y. As resources ar e of ten lim - ic y and proce dur e leve l, th ese in iti ati ve s ca n of te n be ov er - with ite d, thi s may be an ot her area in which collaboration shadow ed by other orga ni zat ional pri orit ies . On e of the oth er organi zat ion s may provide supp lem en tal resource s cha llenge s id ent if ied by HLC study hos - mo st prominent (se e Chapter 7: Establishing Interna l and Exter na l pi tal s is the const ant com pet it ion be tw een C&L se rvi ces ls with the se typ es of in i- Col lab orati on s) . To help hospita an d ot her ho spi ta l priori ties, whi ch of te n re sults in a lack inc lud e the Agency for tiat ive s, ava ilab le resources of fin an cial an d othe r re so urces for C& L ser vi ces. Hea lth car e Re se arch and Qual ity ’s (A HRQ ) report, Is Our Anoth on cha lleng e is a la ck of clari ty in org ani - er comm ac y Meeting ls Pharm Pa tients’ Need s? , which guides hospita zati on al com mu ni ca ti on to st af f re gar di ng the im port ance tin g a health li ter acy assessme thr ou gh conduc nt of the ir of cul tura l com pet ence and id ent if ying wh o, ulti mat ely, is [19 ]. pha rmacy and pati en t needs ete nt ca re. resp ons ibl e fo r prov iding cult ura lly comp Which Writ ten Mate ri alsNe ed In orde r to reso lv e the se cha lleng es, it is impo rt ant for to beTra nsl ated ? or ga niz ati ons to cl ari fy the ir comm itm ent to prov iding Writ teninforma tio nis dif ficu lt toclassif yas “vit al” or ive inf ra - cul tur ally com pete nt care by cre ati ng a support “nonvi tal ,”and some doc ument smay inc lude both ur es that help st aff put st ructur e of pol icies and proced vita lan dnon vi talinforma tio n.How ever, exa mpl es th ese ideals in to act ion. Th e sel f-as ses sme nt ques tion s of vital and non vi talwri tten materi al sinclude: pr ov ided in cha pter 8 can help hosp ita ls and oth er health No nvi ta l: Vita l: iz at io ns fu rt her expl or e the types of poli ci es car e organ •Me nu s •Consent an d •Th ird -part ydo cu - co mplaint for ms me nts, for ms, or •Infor mati on abou t pa mp hle ts distribu ted fre elanguage assi s- as apub lic se rvice tance program sor “Educa tion al mat erials, wealways •La rgedocume nts ser vice s have ,at lea st inSpan ish as far such asen rollme nt •Notice sof eli gibi lit y as inf ormed conse nt docu ments ha ndb oo ks (altho ug h cri ter ia,rights, deni al , “ [and] pa tientedu cat ion mat eri als. vita linforma tio nco n- loss, ordecr eases in Ou rcomp ute rized syst emal so taine dwith in the se be nefits or ser vices has adrop-d own op tion...some do cum en ts may nee d •Intake for ms that of the pri nte dthi ngs are inthe two to be tra nslate d ma yhave impor tan t langu ages. ” con se quen ces Sou rce: Of fice for Civil Right s[20] –A memb er oflea dershi pfrom asou the rn hospi tal 22 ”

23 CHA PT ER4: a Fou ndatio Building n ations and /or pr oced ur es th at wi ll supp ort thei r organiz in bet ter meetin g th e needs of div er se pat ient populations. Ot her res our ce s, such as the Ca lif orni a He alt h Ca re Straight Talk : Model Hospital Saf ety Net In sti tu te ’s Polici es an d Pr oce dur es on Lang uag e Ac cess and the Georgetown Nat io na l Cent er for Cultural Comp ete nce ’s Cultural and Li nguistic Competenc e Policy Assessment , can provide addi - tiona l gu ida nce as hos pi tals work to bui ld the ir support - “I thin kthebiggest chal lenge iv e fou nd atio n of poli cies and proced ures [21, 22] . is maki ng cert ain that sta ffand emp loye es [pract ice ]cult ural sen sit ivit y. “ Thi sisapeo ple bu sine ss and as much - Whi le thes e ty pes of polici es and pro ce du re s are impor as theCEO migh tissue an ed ict. ... ta nt , they ar e on ly one of the buil ding blo cks an d shou ld [cu ltural se nsit ivi ty] do es no thap pen be accom pa nied or suppo rt ed by da ta co llecti on and un less you invest in you rempl oyee s.” moda tion s to pati ent needs eva lua tio n (ch apt er 5), accom –C EO fro mawest ern hosp ital (ch ap te r 6), an d int ernal and ex terna l collabora tions (ch ap te r 7). Fo r example, da ta col le cti on on pati ent nee ds and co mmu nity demog raph ics is cruc ial to devel - opi ng str ateg ic ini ti atives, deter mi ning st aff recruitment ” go als , and develo ping targ et s/staff -pa tie nt co ncordance pa ti ent -cent ered vis its and communica tio ns. Data are nee ded for co ntinu ally evalu ati ng or monit orin g of th e eff ect ive nes s of th ese poli cies and proce dure s once th ey are in place . Rem ember pol ici es and pro ce - tha t while du res that sup port cultural comp etenc e are vita l to me et - up only ing the ne eds of diver se pop ul atio n, the y make on e co mp one nt of the fr ame work. 23

24 CHAPTE R5: Co ll ectin g an d Usin g Da ta to Imp rove Services The co lle ction ving and use of dat a is esse nt ial to impro Exam ples of Demographic ed to se rvi ces develop healt h ca re service s, in clud ing those Datato Collect 17 mee t the need s of dive rse pati ent popul at ions. •Ag e •Pri mary sp oken and/ or In stitu tin g pract ice s to sy st emat ical ly co llec t data allows •Cul tura lneed s* writtenlang uage the eff ecti ve nes s and ut ili zat ion of cu lt ural an d lan guag e •Dietary nee ds* •Race /ethni ci ty to be moni tor ed, measur ) services (C&L ed, an d eval u- •Rel igi on •Disa bi lity* and ated. Th ese practices can be use ful for plan ning •Gend er •Se xual ori ent ati on* to pr ov id e safe , qual ity care and services des igning •Heal th literacy level * •So cioe cono mi cst atus de cr eas e heal th di spar it ies . denotes de mogra phic var iables that may be collected * on the patie nt- and patien tpopulation-le vels only As se ss ingthe Ne edforC&L Services cul - is no “o ne si ze fits al l” plan for prov iding As there char act eris tic s su ch as age , gende r, rac e/ eth ni city, prim ary tur ally co mp etent care, each organi zat io n must assess its literac y, spoke n and/ or wr itte n lang uage , re lig ion , health and plan accor di ngl y. Bef ore deter - and reso urces needs and soc io ec ono mic stat us . serv ices are mos t approp riat e to mi ni ng which C&L ant to col lect and review data to imp le me nt, it is import Ide nt if yin g di fferent po pula ti ons wi th in th e comm un ity ass es s co mmu nity and pat ie nt ne ed s. - al lo ws an org an iza ti on to re sp ond to cha ng ing demo gra phi cs, chan gin g he al th nee ds, and the cha ngin g ma rk et . ic infor - Dat a Demograph y- Level Coll ec ti ng Com munit Among the many ben efit s of unders tan ding the serv ice ma tion ab ou t the se rvic e area popu lat io n is es sentia l to an com mun ity, seve ral hospit als repo rte d an in cr eas e in ma r- or gan izati on ’s abi lit y to ful ly app reci ate and acc ommod ate ket shar e as a re sult of th ei r eff or ts to re ach out to th e co m- 18 Dat a co lle cte d at the com- the need s of its co mmun it y. mun ity and re spon d to th e com mun it y’s health needs . mu nity level pro vide insight into popula tions that activ ely use hosp ital se rv ice s as well as grou ps that may need tar - ge ted ou tr eac h to inc rease access and int eract ion with th e or gan iz ati on . Demog raph ic dat a may in clude a variety of “Col lection ofdatais critica l. Data show s yo uwhoyou rpopu latio n[s][ar e] andwh at atic colle ctio n an d ana lysi s of da ta an d its use in 17 Sup port for th e system lang uagesthe se population sspe ak. Fur ther “ qual ity improv eme nt can be fo un d throu gho ut the cu rrent lite ra tu re . [sc rutiny] of thedataallo ws thefacil itytosee rec omme nds that ho sp itals “i mp le me nt a The HLC Rep ort of Find in gs work unif orm frame for the co llec ti on of data on rac e, ethni ci ty, and wha tservice sthe yaremos tap tto see k. lan guag e” and that "res ea rc he rs sho uld partn er with ho sp ital s to us e Itallowsthefaci lityto de velop sta ff train ingbase d str ati fie d quali ty me asu rem ent data to disc ern poten tial di sp ar iti es an d on thei rcu ltures as we ll asme dicalrisksan d l and lin guis ti c com pete nce to up meas ures of cultura dev elop follow- mon it or act ions toward im pro ve me nt ” (Rec om men datio ns 2-1 and tend en ci es. Dataallows [huma nresources ]to 2-6) . Se vera l nati on al stan da rds also requ ire the collec tion of co mmu - con duct anannu al com pa riso nofem pl oye emix nity - and pa tient -le ve l data, in clu di ng CLAS Sta ndard 11, “h eal th car e cul tural , and orga ni za ti ons shou ld main tain a cu rren t de mo gra phic, to co mmu nity an dpa tien tload.If thepat ien tdat a epi demiolog ica l pro file of the com mu nity as well as a nee ds as ses sme nt doe snot prop or tiona tely match theco mm uni ty to accurat ely plan fo r an d imp leme nt servi ces that re spo nd to the dat a,thenthefaci lity mus tas kif there isarea son cultu ral and li ngu ist ic chara cteri stics of the se rvi ce area,” and Joi nt tha t medic al rec ords con tain “th e re quire Com miss ion st andards why thatpo pul ation is not acce ss ing se rvices. pat ient ’s lang uag e and co mm uni ca ti on nee ds.” Wh at ismissi ngfromtheser vic esorarethe ir 18 As mentione Communi cat ion — Improv ing Care , d in Improving needseve naddr es se d? ” 24 orga ni za ti ons shou ld colle ct “po pu latio n-level in form atio n abou t its s an d the ir co mm un icatio n communi cat ion-v ulnera ble po pu lation –H LC TAP memb er need s” (C onte nt Area 2, Pe rfo rma nce Exp ectati on 4.0). In add iti on, izatio n work s with co mmuni ty and it is recommend ed tha t “the organ s that servi ce its co mmu ni ty to collec t info rm atio n ad vocacy group abou t new and emergin g raci al, ethni c an d la ngua ge po pu lati ons ” ” n 4.1). (C onte nt Are a 2, Perform an ce Expe ctatio

25 CHA PT ER5: ting Dat a to Imp rove Services Collec an d Using abl e to con fiden tl y st at e tha t thi s inf orma tion is colle ct ed So me hos pita ls co llect ed com mu ni ty-le vel data by dif - co nsi st ent ly. Rac e and et hni cit y data are of ten more performin g a com munity health nee ds assessment. fic ul t to co ll ect . The curr ent clas sific atio n of the Office vari - y heal th nee ds can be asse ssed through Com munit of Ma nage ment an d Budg et (OMB) doe s not identi fy sur - ous meth ods , inclu ding con du cti ng publ ic forums, cat ego rizat ion of et hnici ty be yon d “La tino/Hi spa nic ” or ve ys , or foc us gr oups wi th me mbe rs and le ad ers in the nt when “non-L atin o/ Hispan ic ” [24] . This is in sufficie un it y [23]. In addition, data ar e avai lable rega rding comm org an iz at ion s se rve larg e popu latio ns tha t do not ide ntify rac ia l an d ethn ic di sparit ies in heal th care that hospit als tions . th em sel ve s among the ex is tin g OMB cl assifica ca n us e to be tter un dersta they serve . nd the community at ion ca n prove to be colle ct ing this inform In add ition, on ag e, ge nd er, race /et hni ci ty, primary Data spo ken sens itive bot h to pa ti ent s and to the sta ff wh o ar e as ked to an d/or wr itt en langu age, religio n, so cio econ omic stat us, co ll ect it. and other demo gr ap hic characteri st ics can be accessed co unty, and muni cipa l fro m sever al sour ces, such as state, figures; de partme nt s of he alth; national ce nsus and Not es on Collecting Race and Uni ted St ate s Dep artment of Educati on statist ics. One Et hnicity Dat a hos pit al conv ene d a st eeri ng commi ttee to review dem o- The Hea lth Res ear ch and Ed ucati onal Trust graph - y to de termine ic data from the communit commu Dispa rities To olki t(ww w.h retd ispa riti es. org) is a ni ty he alth ne eds an d plan for appr op ri ate services. fre e, va luabl e resource tha t pr ovides reco m- me nda tion s and gui del ine s to facil itate the Col lecting Pat ie nt- Le vel Data Co ll ecti ng dat a on age, pro ce ss of collec ting race and et hnicit ydata [25]. sp oke n and/or writte n ge nd er, rac e/ ethn ici ty , primary Inclu de din the tool kit are train ing guide linesand langu ag e, relig io n and othe r demograp hic charact erist ic s sc rip tsforstaffto use whenco llec ting the se da ta ter s can help organizations moni - dur ing pa tien t encoun from pat ients. to r whic h popula tio ns currently seek C& L service s and 19 In or der d in the futu re. wha t serv ic es sh ould be provide to mak e sure that the appro priate da ta are colle ct ed, org aniz atio ns ma y ask pa tients ope n-e nd ed questi ons back - suc h as, Is the re anythi ng els e ab out you , you r cultural help gr ou nd, or you r famil y that we shou ld know that might “We have be en doi ng resea rch on us pr ovi de the be st quality care for you? Quest io ns such as theinterne tnotonl yonce nsus dat abut inf or mation to be cap - these al low un ique patient-level edu cat ion da ta[aswe ll]...The [stee ring] and addre ssed. tured “ co mmi ttee wi ll look attha tand sa y, ‘Here’s wh at our servi ces looke dlike this yea rfor our It is impor tant, of cours e, to ensure tha t the data are accu - pat ient s; these are the majo rlangu ag es we rat e and sy st ema tica lly collected. As discu ssed in Chapter interp ret ed, he re are so me of the di fficul ties 4: Bu ildin g a Foundation, several hospit als have imple - we ha d, he re’ swhatour commun itydemo - e men ted po li ci es to iden tify and tra ck a pat ient’s languag grap hi cs look like -doe sit ma tch up? ’...We the co nti nu um of care , th oug h few are nee ds thr oughout are goi ngtodothi son an ann ual ba sis by looki ngatint ern aland ext ernal data to see 19 possible, Impro ving Communica tion — Imp roving Care states that “when how weare doi ng and [whet her] our se rvic es on an indi vid ua l’s ra ce an d ethnicity is collected dir ectly in fo rm ation are st ructu red correctl y.” fro m th e individu al,” an d that an “organ iza tion ensures that informa - 25 tio n on how individuals including is collected, nee d to co mmu nicate –C &L servi ces staf ffrom a pr imary language” (Co ntent Are a 2, Pe rfo rma nce Expectations 2.1, 3.0, and 3.1 ). CLAS rd 10 re qui res health care organiza tions to Standa no rthe aste rn hospi tal “ens ur e th at data on th e indi vidu al pa tie nt’s/consumer’s ra ce, ethnicity, and spok en and writt en lan gu age are colle cted in heal th recor ds, iza ti on ’s man agement sys tems, inf ormation in tegr ated into the organ ” d. ” y update and per iodicall

26 CHA PTE R5: Colle cting and Usi ng Dat a to Impro ve Se rvices relig iou s an d spir itu al car e serv ic es , and special dieta ry A no rth eas tern hosp ital col le ct ed and use d data on race, reque st s th at are of a cu ltu ral natur e. et hnicit to st re ngt hen patie nt- lan guage y, and pr imary cente red ca re and sta ff recr uit ment process es , and to com - Col lec ti ng Da ta on C&L Pr ov id in g lan guage Servi ce Us e As C&L ser vi ces staff mes. par e cl inical outco said, se rvic es is essential to meetin g th e comm unic at ion need s of “[W e’ re] makin g the commi to tmen t as an org anization div er se pa ti en t popu la ti ons . Co lle cti ng dat a on how ofte n with that col le ct race- and ethni cit y-re lat ed data. Along lan gua ge ser vi ce s are us ed allow s an orga ni zat io n to qu an - comes the co untr y of birt h and pri mary language. It ’s tif y us age , ju stif y a need for the servi ces , an d str engthen tie s fo r us to see how can we ope ned up a lo t of opp ortuni fin ancial an d sta ff su pp or t to pro vi de th os e se rvice s. tak e tha t infor matio n and make sure that it conti nues Hos pita ls me asu re d langu age se rvi ce use by doc um en tin g ho ut his/h er sta y here, t throug wit h the patien and also ca re. er s dur ing patient the fre qu ency of inte rp ret er encount ati on int ernal ly to streng the n ho w can we use that inform In terp rete r en co unt er s ca n be do cum en te d in a var ie ty of of our pat ien t-ce nte re d care [and] our or enhan ce some wa ys, dep en ding on an orga niza ti on’s polic ies, suc h as rate rec rui tment pro ce ss es.” This hospit al pla ns to incorpo dire ctly in the med ic al re cord or in interp ret er logs tha t are the se demographic data int o the ir strat egi c and bus ines s mai nta in ed by the in te rpre ter ser vic es de par tmen t. it y. This pract ic e may plan s to bette r se rv e their commun Doc um ent at io n may als o incl ude in terp reter sche duli ng to in clu de dat a on re lig iou s or spirit ual als o be exte nded dat aba se s, giv en th at the org aniza tion ha s an ele ctronic sy s- prefe rence s, as these dat a are al so imp ort ant for asse ssin g tem to pl an and trac k en co unte rs. The type of la ngua ge servi ce s. the nee d for C&L ser vic e us ed may als o in fl ue nce how usag e da ta ar e col - ion on th e lec te d. For exa mpl e, re cords cont ain in g in format to gath er Othe r ho spit als are usi ng pat ient focus groups 20 use of te le ph on e in te rpr etin g servic es may be kept by in di- A HLC TA P inf orma tion reg ard ing pa tie nt nee ds . vidu al dep art me nt s rat he r th an in a cent ra lize d loc atio n. s r in supp or t of th is pr acti ce sai d, “Focus membe group on sur - are . . . a way to colle ct data, but ins tead of relying Docum ers ma y also be useful ent ing int erp ret er encount ve ys, whi ch ha ve a very low rat e of ret ur n for th e limit ed cati on for the an alysis of sen tinel even ts. As communi Englis h pro fici ent (LE P) po pu lati on, you get your data iss ues ha ve bee n rep orted as the ro ot caus e of over 60 % of ts to fro m the sour ce, prov id ed you can ge t eno ugh patien sen tinel eve nts [8] , coll ec tin g da ta on in terpr et er encou n- pa rti cipa te.” Moni tor ingC&L Servic eUtil ization To be tte r eval ua te an orga niz ation’ s cu rren t C&L serv - r how ofte n th e services are ic es, it is crit ical to monito 21 us ed . Coll ect ing data is one way to measure the fre - of the ser vic es que ncy of C&L servi ce prov is io n. Some “We tellthem exac tly wha tthe la ngua ge serv ices, tha t may be moni tored include doc ument ation nee ds to be. Wetellthem the lang uageorpr ef erredmetho dofco mm uni cation “ s Im pro vin g Pat ien t Ca re — Im pr oving Commu enco ur ages hospital 20 nic atio n and the typ eofco mm unica tio nass istanc e basis to get feedb ack on th e perc ep - on a “r egular groups to con ve ne focus need s of communication-vu ln era bl e ti on s of care and communication wh et her itwas atelep ho nic, ba ck up langu ag e nt Ar ea 5, Perfor mance Expectation 6.3 ). popu lati ons” (Conte ban kempl oye e, orspe ech impair ed. ” 21 CLAS St andard 4 requir es that “heal th care or ganiz at io ns must offer and –C&L services staf ffrom a includ prov ide lang uag e as sist ance ser vices, st af f and int er - ing bilingual 26 north easte rn hospi tal with limit ed Engl ish /consumer pret er servi ces , at no cost to each patient , in a timely profi cien cy at all point s of contact dur ing al l hou rs manner HLC Report of Fin di ngs tha t “h eal th of ope rat ion.” The al so recommends care int erpre ters should dur ing al l communication be used to facilitate ” inf orm ed cons ent pr ocesses involving patient s with limited Engl ish pro fi - a pa tient’ s shoul d be used as a resource l brokers cie ncy, and cultura when 4-2 ). cult ural be lie fs impa ct car e” (Recommendation

27 CHA PT ER5: an d Using Dat a to Imp rove Services Collec ting em erg e fro m thes e dat a, in clu ding the ne ed for edu ca - addi tiona l info rmat io n. One sout hern te rs can pr ovide tio n and tr aining to incr ea se aw ar ene ss of the ava il abi li ty event that had an ad verse ho spital rep or ti ng system of lan gu age serv ices , to ens ur e tha t the servi ce s are in clu ded da ta on pa tients ’ langu ag e needs and whet her or - acce sse d and provi de d co rre ctl y, and to addr ess compli docu - rete r was prov ide d. The app ropriate no t an interp an ce prob lem s wit h or gan izat ion al pol icie s or proced ures men tation of la nguage ser vices, combi ne d wit h an adv ers e fo r dat a co lle cti on . Dat a on in te rp rete r encou nter s an d infor - ev ent repor ti ng sy stem that connects inter preter langua ge se rvi ce use may also pro mot e changes in st aff mat ion wi th even t details , ca n provide furth er insight int o recruit me nt tha t al le vi ate wo rklo ad conce rns . th e effe ctiv eness or weaknesses of sp eci fic interpreting meth ods and provide dat a for fu tu re stu di es . Us ing Da tato Impr ove C&L Serv ices One cav ea t of documenting inter pr ete r encounters to Da ta col lect ed be fore, duri ng , and af ter the prov is io n of use is that document service mo nit or la nguage ati on C&L serv ic es ca n be us ed to iden tify are as for serv ice ion. sh ou ld be ma nda tory thro ugh out the organizat im pr ov eme nt or exp ansi on . An alyz ing da ta fro m di ffer ent dat a col lecti on may ina dver - Sp ora dic or in con sistent sou rc es an d str atify in g it by va rious fact or s can hel p te nt ly diminis h the import ance of prov iding language or ganiz ations stren gthen thei r C&L se rv ice s and addres s serv ices, base d on an underestimat of e of the fre quency di spar ities in care for div erse patient pop ulat io ns. of the ne ed fo r lan - use or an in accur ate representation gua ge servic es. Or ga nizations are enco urage d to develop Est ablishin g a Base lin e of C& L Se rvic es Bef ore hosp i- the routi ne do cumen ta - syst em-wide pol icies to require ta ls ca n ev al uat e C&L service imp ro ve me nts , it is impo r- the con tin uum encounters throughout ti on of inter preter ta nt to ass es s the org ani zat io n’ s com mi tme nt to pro vidin g a Foundat of car e (s ee Chapte r 4: Building ion). se rvi ces to diver se pa ti en ts an d esta bli sh a bas elin e of 22 th e servic es pro vide d. A mi dweste rn ho spi ta l hi re d a of Org ani zation s may als o consid er ext endi ng the practice rs to ad dre ss other C& L doc um enti ng int erprete r encounte ser vi ce s. Doc um en ti ng pat ient enc ou nt ers with religious an d spi ri tual care prov iders can help org aniza tions meas - ure the freq ue nc y of use fo r such se rv ic es . It is als o us eful “[We ]doroot cause an alysi s, [an d] the to docu me nt info rma tion regar ding pa tient dietary pref - lang uageissues that come upin root ca use can be cons idered as care ere nces so that thes e pr eferences ana lysi sare interp ret ationissues. Was [the “ is pr ov ided. For example, dietar y if the pat ie nt has specific informa tion] ade qua tel yinterp rete d? Do we pref er ences su ch as vegetarian, ko she r, or halal, th ese real lykn ow wh at wa sint erpre ted? One of the sh ou ld be doc ume nt ed so hos pita l se rvi ce s can be adapted thing swe’ve do netoassist wi th that is we now have int erp ret ers si gn on [forms] that to acco mmod at e the pa tient’s er (s ee Chapt specific needs [iden tifytha t]the yha ve int erpre tedfor 6: Accom mod ati ng the Needs of Spec ific Populatio ns). [pat ient ]ca re,espe ci al ly on conse nts. ” Data Bui ldi ng Upo n C& L Service Utilization –CEO from awest ern hospi tal Qu antifia bl e la ngua ge service provi si on data can also co nt ri bute to studies beyond merel y unde rstanding how ” of ten pati ents us e language service , with s. Fo r ex ample the pra ctice of do cu menting inter pre te r enco unte rs as a 27 mod el, data reg ardi ng the frequ en cy of language service 22 CLA S St an dar d 9 ad voc ate s th at “he alth car e or gani zati ons shou ld us e ma y se rv e as a foundation for in quiries into th e eff ec - ng organi zati onal sel f-ass ess me nts of CLAS- cond uct ini tial and ongoi re lat ed ac tiv ities and are encou rage d to inte grate cul tur al and lingui stic ti ven es s of in terp reter servic es, the alloc ation of resourc es, com pete nc e- rel at ed meas ures into th eir inte rnal aud its , per for mance cl inic al outcome ons, and patie nt e populati s for divers imp rovem en t prog ram s, pati ent sati sfa ctio n as se ssm ents , and out - com es-ba sed eval uat io ns .” of staf fi ng issue s may also A number sat is fa ctio n st udies.

28 ve Se rvices Usi ng Dat a to Impro and cting Colle CHA PTE R5: dem og rap hic ch ar act er is tic s can help organi zati ons better con sult ing fi rm to conduct a compreh en siv e diversity audit dat a n, these asse ss the nee d fo r C&L service s. In additio acr oss mul ti pl e cat eg ories, ity, divers inc lud ing supplier can be use d in th e anal ys is of ser vic e an d te chn ic al quali ty bui ldi ng ac cess ib il it y, po lic ie s, edu cat io n pro gram s, com - meas ur es (inclu din g cl ini ca l ou tco mes ) and adve rse ev ent s muni cati on , and mar keting. Ac cor ding to th e hos pital ’s as a wa y to se parate an d st rat ify resu lts by demo gr aph ic in CEO , “[I t gav e] us a baselin e on how we were [doing] 24 cat eg or y. Org an iz at ion s are enc ou rag ed to use the de mo - see, co mpared to the industry, es. We could tho se categori ic data th ey coll ect to ide ntif y dis pari ti es in the ca re graph too bad, or [th at] we have a long way that we are no t doing and ser vice s pr ovid ed fo r dive rse pat ie nts . , whic h to go. . . . We had our res ult s given to ou r ex ecutives we pr io ri ti zed and said, ‘O kay , base d on al l of that info r- Stra ti fying da ta by de mo grap hic var iabl es can he lp hos - .’ So we se t some pri orities.” ma tion, we have to work on thi s pi ta ls pinp oint ar eas in which pa tient s fr om spe ci fi c pop - ul atio ns nee d tar get ed ser vic es or prog rams. For ex amp le, Pat ient Feed ba ck Co llec ting patie nt fee d- ining Obta a south ern hos pita l strati fied th eir pati ent outc ome dat a bac k dat a fol low ing th e provis ion of C&L se rvices al lows by pri ma ry la ngua ge, an d the re sul ts pro mpte d th e te tho se se rvices the an organ izat io n to evalua from orga ni zat ion to transl at e pat ient educa ti on mat er ials in to pa tient per spectiv fe ed bac k data can help hos - e. Patient ot he r lang uag es to impro ve cl inic al outcomes for pati ents deter mi ne the effecti ve ne ss and app ro pria teness of pitals wh ose prima ry langu age was no t En gli sh. Ot he r hos pi - th eir C& L serv ic es or sugge st ad di ti on al serv ices. Sev eral or ta ls str at ifi ed adve rs e eve nt data by pr imar y lan guage, HLC pa ti ent co m- and rev iewed stud y hosp ita ls col lected st ra tif ie d th eir performan ce an d qu ali ty indi ca to rs by rac e y issues plai nt and /o r pati en t satisf act ion data to identif and et hni ci ty . Using data to be tte r unde rs tan d how ce r- ser vi ces. tha t cou ld be be tter addre ss ed by thei r C&L tain pop ula ti on s re ce iv e ca re can als o inf orm th e wa y One cavea t to th is practice is that pati ent complaint and or ga niz ati ons exa mine th eir core measu re s. sur - satis facti on data ar e often co llec te d thro ugh paper vey s, and orga ni za tio ns ma y ne ed to cond uct focus groups or ada pt the ir wri tten data col lectio n tools to 23 y reso ur ce s and Co mmunit accom moda te C&L needs. lead ers may also be helpf ul in both obtai nin g and assist - in g in the ana ly sis of patien t feedb ack (see Chapter 7: Es ta blish ing Inter na l and Ex ternal Coll aborations). “Focus grou ps are excel lent ways to ‘hear’ about ho wwel lornot afaci lity isdoi ng. A north eas tern hos pit al ob tai ne d pat ie nt fe edback throug h Th ey ca nalso serve as anoppo rtunit yfor “ wi th sta ff ma na gers to ide n- info rma l pati ent inte rviews thecommu nitytolearn ab out ho wthe faci lity e ti fy pati ent car e issue s as a way to co llec t dat a to improv opera tes. Ifdo necorre ctl y, the yal low a facil itytolea rn fro mpo pul ation groups who care an d C&L se rvice s. In some case s, bil in gu al st aff int er - may not pa rtici pat einpape rsurveys. ” iew s. Th e pot entia l wealt h of du ri ng pat ie nt interv preted can be data ob ta in ed from dir ect in tera ct ion wit h pa tients –HL CTAP member used fo r many purp os es and provides an inv alu abl e pa tie nt pe rspe ct iv e on exist ing and muc h- need ed serv ices . ” St ratif yin g Data As ment ione d earli er, co llect ing accu - ity , pri - ra te da ta re gar di ng patient age, gen der, ra ce/ethnic 28 and ot her mar y sp oke n an d/ or writ ten lang ua ge, religion, sug gest s th at the “collec tio n and an alysis of 24 The HLC Rep ort of Fi ndi ngs adver se even t da ta by la ng uage, ra ce , and et hn ic it y sho uld be unde rta ken and be sta ndardiz ed as a mea ns to su ppo rt pa ti ent sa fet y in itia tive s” 23 As st at ed in CLAS Stan dard 13, “He al th care orga ni za ti ons shoul d fu rther Im pro vi ng Comm uni cation— Im pr oving Care (Reco mme nda tio n 4- 7). ct and grie vanc e res olu ti on proc es ses are cul tu ral ly ensu re tha t confli in form at ion wit h advises that “th e org an iz atio n [c ro ss-lin k] dem og raphic se nsi ti ve an d cap able of iden tif yin g, pr eve nti ng and and ling ui stically clin ica l quality mea sures” (Co nten t Area 2, Perf orm anc e Expec tation 6.0). re sol ving cross -cult ura l con flic ts or co mp lain ts by pati en ts/co nsu me rs .”

29 CHA PT ER5: an d Using Dat a to Imp rove Services Collec ting Conclus ions Alth ou gh Exp lorin g Cul tural and Lin gui sti c Ser vices in the Thi s cha pter highl ig hts var ious consid er ati ons when devel - Nat ion’s Ho sp ita ls: A Repor t of Findi ngs (HLC Report of oping or evalu ating curr en t pr ac tic es to coll ec t an d use dat a Fin di ngs) logy as a tool to facili tate techno ad voca tes using 25 to improv e C&L se rvice s. Whi le ma ny hosp ita ls across the the re were no practi ces ident ifi ed in dat a st rati fica tio n, Uni ted State s alr ea dy col lect the se data, few ho spi tals have addres thi s st ud y that specif ically se d the use of inf orma - deve lo ped syst ems for usi ng th em to guid e se rvi ce devel - ti on sy st ems to st rati fy data. As this repo rt focuses on the opment qu es ti ons The sel f-a sse ssment and imp ro vement. the current prac tices perform ed in hos pi ta ls ar ound pro vid ed in ch apt er 8 were deve lop ed to gene ra te ideas and co untry, one possibl e ex planat ion for the absence of tech - discus si on abo ut identif yi ng th e typ es of data to col le ct, and nolo gy- bas ed pra ctices may be a lack of reso urces exis ti ng data base s tha t ca n be used , me thods for co ll ect in g avail ab le in the pres ent envi - tec hnolo gic al in fra st ructure the dat a, and wa ys to use th e data to impr ov e ser vice s. ns ro nment. However , it is als o pos sibl e th at organizatio th at hav e the te chn ol ogy in place do no t use their da ta to servic es , A thor ou gh und ers tan di ng of the need fo r C&L the fullest pot en tia l. Giv en the nati ona l attentio n to de penda bl e inf or mati on re gardi ng th e use of thos e se rv - dev el oping an d ap pl ying sta ndar ds fo r hea lth in fo rma - C&L ice s, and th e usef uln es s of tho se da ta to improve hospi - ti on te ch no lo gy and electr onic medic al rec ords, se rv ice s ca n all co ntr ibu te to an organi zation ’s ability to suppo rt the inclusio tal s must n of rac e, eth nici ty, and ide nti fy and mo ni to r health dis pari ti es and prov ide saf e, m, mandatory la ngu ag e as minimu fiel ds fo r the collec - qual ity heal th car e to cul tu ral ly an d lin gu ist ical ly diver se tion of C& L-r ela ted data. Data sys tems that support th e pati ents . The data co lle cte d may als o be used to in form the use of these dat a will allow co llecti on an d facilitate short - an d long-te rm org an iz at io na l pla nn in g (se e ho sp itals to ref in e their qua lity, perf ormance, and out - Ch apte r 4: Bui ldi ng a Foun dati on), help devel op C&L- e C&L serv ice s. co me me asu res in order to improv spec if ic ser vi ces and pro gra ms (se e Ch apt er 6: of Spec ific Popu lat ions ), and Acc ommo datin g th e Needs ide nti fy li mi ta ti ons in staf fing and re sourc es th at collab - 7: or ativ e par tn er shi ps ma y alle vi ate (se e Cha pter “We’ ve begun to bre ak down not just Est abl ishi ng Inter na l an d Exte rn al Co ll aborations). wh othe patients are, but we ’ve also beg un to look at pati ent ca re issue s[and ]over all “ per formance and quali ty indi ca tors. ... We’ ve just start ed inthe last ye ar to break tha tdown into di fferent cul tur es orethnicit ies to se eif there are any di ffe rence sthe re and “The perf orma nce improve ment cycle dra wco rrelations to se ewhy one popula tion st artswi thcycle thinki ng ...Ho wdo you has alonger length of stay. Are ther e kn ow ifyou’ re provi din ggood servi ces or “ reso urce issues? Socio eco no mic levels? not ?Whatda ta do you have that show sthat avail ab le to the mafter Are ther eresources yo u’ re do ing whatyou wa ntto doand you’ re di scha rge?. ...[Can we] mayb echang ethe not provi din gse rvi ces you wan ttoprovi de? wa ywe treat pat ient s[as we go ]forwa rd?” If yo u’ re no tmee ting you rgo als, then you –A mem ber of lea de rsh ip mo ve into thenext part ofperfo rmance fro masouther nho spit al imp roveme nt wh ich is pl anni ng, pl ann ing 29 for impro ve ment .” –A membe rof lead ersh ipfrom ” awe stern ho spit al 25 The HLC Repo rt of Fi ndin gs in form ation re com me nds that “health groups tec hno log y work ng need to de te rmin e practic al way s of integrati pati ent demog raph ic data su ch as ra ce, ethn ici ty, and prim ary ” n 2-5). lan guag e int o information system s” (Re co mme ndatio

30 CHAPTE R6: g the Need s Acc om mod atin of Specif ic Po pul at ion s By bui ldi ng awar enes s of how communi ca ti on con - datin g th e needs of spec ific popu lat ions includes Ac commo tr ib ut es to pa ti en t saf ety and se tti ng exp ec tat io ns fo r pra cti ces ai me d at providing - sa fe, qu ali ty care and decreas eff ect ive comm unic at ion at al l le vel s of the org ani zati on, in the serv - ing he alth di sp ari ties for pa rti cu lar popu lations 26 may be abl e to dim in is h res is tance to C&L hos pitals in i- al l th e pract ices ment ione d in Al though ice com mu nity . ti at ive s and ma ke effec ti ve comm un icati on a cus tomar y patients, th is repor t ca n hel p hos pital s care fo r their diverse pa rt of the ir ove ra ll se rvi ce s. the maj or it y of pr ac tices repo rt ed by hea lth or gan iza tion s ha ve a macro-le vel appro ach. In cont rast , this chapter So me or ga niz at ions ma y el ect to sta rt the ir tra inin g efforts foc us es on mic ro -leve l pr act ices desi gned to me et the chal - wi th high- level st aff to ensu re leadershi p buy-i n for C&L- le ng es of ce rt ain popu lat io ns. Th e pra ctices inc lu ded also re lated act ivi ties. One nor thea ster n ho spita l dev elo ped a re late to othe r the me s in this repo rt , bu t are placed in this se nio r- level tr aining sessi on tha t had a “fo cus on co mmu - ch ap te r be ca use the y bes t reflect the orga niza tion al eff ort s nic atio n as the cor nerst one to pa tient sa fety and di scu sse[d] addr ess th e lang uage , cul tural , and he alth th at directly ne gat iv e outc om es cor rel at ed to [l imit ed Eng lish prof ic ient] li ter acy issu es of spe cific po pu lat ions . and non -Engli sh sp ea ke rs. ” Hospi ta ls ma y gain stron ge r of or ga ni za ti ona l su ppo rt fo r C& L initia tiv es if me mbers Pr omo ti ng Sta ff Awa re ne ss through ca ti on leade rs hip cham pio n ef for ts for bet ter co mmuni Tra ining,Di al ogu e,andSupport be twe en st aff an d pat ients. ts, In ord er to provide safe, qu alit y hea lth ca re for all patien it is ess en tial to in te gr ate th e co nc ept of cu lt urall y com pe - An ot he r wa y to enha nce commu nica ti on with patients te nt care int o staff traini ng and ed ucati on as a mea ns is to pr ov ide sta ff educ ati on on how to wor k with a pr o- 27 One of the chall en ge s hos - tow ar d quali ty imp rovement . fe ssi ona l health ca re inte rp re te r duri ng me dic al en coun - pi tals repo rted is a la ck of aware nes s amo ng staff re gardi ng 28 te rs. It is imp or ta nt to ack nowl ed ge tha t prof es si onal and issues (C&L) th e imp or tan ce of cul tur al and lan guage healt h car e int erpret ers are a key com pone nt of the me d- how they affec t pat ient care. To add ress this challenge, hos - facilitat ica l tea m and have abi li ti es th at exte nd be yond - pita ls are provid ing sta ff wit h tra ining that encom pass es a in g com mu ni ca tio n betw een pat ie nts an d provi de rs. from self -s tu dy edu cational mater ials to ran ge of acti vities, Give n tha t int er pr eters have re ce iv ed the appro pria te inter ac ti ve gr oup lear ning ses sio ns . to lend tr aini ng, th ey may al so be used as cul tu ra l brokers insig ht in to cu ltur al prac ti ce s and beli efs and identi fy Tra inin g to Sup po rt Effe ctiv e Communicat ion The 29 po te nti al cul tur al co nfl icts . role of effe cti ve co mm unica tion in pa tie nt sa fet y ha s [13] . be en we ll documented in the cur rent lit erature A nu mb er of hos pi ta ls pro vi de d sta ff wi th la ngu age - Or ga niz atio ns ca n hig hli ght the imp ort ance of commu cou rses suc h as Eng lis h as a Seco nd Langu age, acc ent nicat ion th ro ugho ut the cont inuum of care by training re du ction, and one -da y ele me nta ry me di ca l la ngua ge ni cati on skil ls with pat ient s. staff to im pro ve thei r commu cla ss es. Wh ile suc h cou rse s may alle viate so me spec if ic St anda rd 1 state s, “He alth care organi zation s sho uld ens ur e th at 26 CLAS icat io n barr ier s staff mem ber s may have , the y co mmun effec tive , und er - rs rec ei ve from all staff me mbers pat ie nt s/ consume do not pr ovi de a me ans of br id gi ng lan gua ge ba rri ers st an dable, and re sp ectfu l care that is pro vi ded in a ma nn er comp ati ble hea lth beli efs and pra ctic es an d pre ferre d language wit h the ir cultural .” 28 As mention ed in the HL C Report of Fin di ng s , “He al th car e inter prete rs rec om me nds tha t “hospita of Find ing s HL C Report 27 Th e ls sho uld engage uni cati on duri ng al l infor me d con sent sh ould be us ed to faci li tate comm and ab ou t mee tin g the nee ds of diverse popula tions” staff in dial ogues pr oce sses inv olv ing pa ti ents wi th li mi te d Engl is h profi cie ncy, an d 30 on way s training staff shou ld be pro vide d ongo in g in-service “hospital cul tural brok ers shoul d be us ed as a re sou rce when a pati ent’s cul tur al including regula r to meet th e uniqu e nee ds of the ir pa tie nt population, nd ati on 4-2). bel iefs im pa ct car e” (R ecomme in -s er vices on how an d when to ac ce ss la nguage services for patien ts with 3-1 and 3- 2). CLAS prof ic ie nc y” (R ec om men dations li mit ed English 29 Gui di ng pri nci pl es and compe ten cie s for cultur al br oke ri ng ens ure th at should 3 req uire s that “hea lth care organizations Standard Brid gi ng the Cu lt ural Divi de in He al th pr og rams are out li ned in staff at all leve ls and ac ro ss all di sc ipli ne s receive ongoing edu cation and av ailable Ca re Set ting s: The Essent ia l Ro le of Cult ur al Brok er Prog ra ms , tra in ing in cultura lly and lin gui sti ca lly ap propr ia te service del iver y.” at www. cu lt ural brok er.i nfo /in de x.h tml.

31 CHA PT ER6: ting ations Acco mmoda th e Need s of Spe ci fi c Popul St af f turno ve r is exp ec te d in hospit als , an d it is imp ort an t betw een staff an d patie nts. Staff sh ould be caut ioned not tr ain in g to main tain a con sist en t sta ff to dev elo p ongoing second-language to re ly upon elementary skill s to com - er of co mmitm ent to cult urally comp et ent care. A numb the use of professional muni cate wi th pa tients ; ins tead, te achin g hospita ls work ed wi th the ir tr ai ni ng prog ra ms is vital he alt h ca re int erpr eters to avoid ing patient- to fo rm ali ze cu ltu ra l compe tr ai ning and incorpo - tency cati on . pr ovi de r misc ommuni ra te it into the ir res id en cy pr og ra ms. As a me mb er of lea d- ershi p fr om a we ste rn ho spital de scr ibed , “We [h ave] a Sev er al of the ho spit als tha t pr ovided staff language classes thr ee-y ea r cu rric ul um th at in cludes topic s on va ri ou s cul - repo rte d th at the classes were offered on ly to spec ific clin - , tu res. In part icular , we talk ab out Hispa nic , Vi et namese ic al st af f, such as phy sicians. Hospi ta ls sho ul d keep in mind an d Middl e East ern cul tu re[ s] , tea ch[ in g] [sta ff] ab out tan t for un ic ate effect ive ly is impor th at th e abili ty to comm vari ou s aspe cts of [pat ient s’ ] cul tur al need s, and use ac tua l who in terac t and com - all staff , as it is no t onl y phy sicians pati ent case s to [i llust rat e] ne eds .” mun ica te wit h pat ients during the hea lth care enc ounter. In addition to rt Cultural ing to Suppo Co mpetence Train Cult ural Compet ence addr ess ing the imp ort anc e of eff ect ive com munication, hos - Learning Modules pital s should also co nsid er pro viding st aff trai ning aro und Anumb er of lea rnin gmo du les rel at ed tocult ural 30 Whi le it is equal ly . cu ltur al competence and sensitivity comp etence are ava ilable onl ine inclu ding the catio n, traini ng to impo rtant to tr ai n on ef fecti ve communi Hea lthResou rces and Service Ad mini stra tion’s sup port cul tu ra l co mpetence serves a di sti nct function. Uni fiedHe al th Commun icat ion 10 1: Add ressi ng Heal th Lit erac y, Cult ural Comp eten cy, and Hosp ital s repo rt ed tha t sta ff ed uc atio n sup po rti ng cultural Li mi ted Eng lish Pr of ici en cy (ww w. hrsa. gov/ heal thlitera cy/ trai ning. ht m) [26 ], and the Of fic e nce took ma ny fo rms, incl udi ng staff in -service s, compete ofMinor ity He al th’s APhy sician ’sPracti cal Gui de and specific wi th guest sp eakers, onl ine resources, sessions (cccm. think to Cu ltura lly Co mp eten t Car e cul tura l-focus ed cla sses. Top ics va rie d fr om cul tural tradi - cul tural health.o rg) [27] . and faith ti on s and rit ua ls to th e roles of tra diti ona l healers At one sout hern ho spita l, in th e heal th and he aling process. lead tr aini ng sessions for exam pl e, pharm for physi - acists with es they ma y encounter cian s on ty pes of herb al remedi th eir pat ient po pula tio n. As C& L serv ices staf f de scrib ed, doct or s have learn[ed] to beco me aware of different “Our and of th e va ri ous mixtures, he rb al prep ar ati ons and some “[We ]do cul tura lco mpet ency trai ni ng of these th ey ar e aw ar e of some of the medica l si de-effects fortworea sons. We have avery diverse of expe ri ence in askin g and mi xt ures. They ha ve a wealth st aff and wa nt to deve lop coh esio nbetw een ass essi ng wh at pa tients are taking.” As a result, physicians “ them, andthe more und ersta ndi ng tha twe a more may be bett er able to bo th collect accurate assess - ca ncrea te, the be tterthese rvi ces wi llbe . ment of what th eir pati ents are taki ng as well as have a mor e We try totra insta ff onthe pa tien tpopu lations comp le te under ie s may sta ndi ng of the imp act the se remed we ser ve. We don’ tdoenou gh of itand Sta ff tra ini ng that supports hav e on thei r pa tient s’ health. fra nkl ywedon’ tdoenou gh research to ga ining knowledge cul tura l com pet ence may also include un de rst and wh at cul tura llysensi tive ca re is. ” ura l encounters, cro ss-cult such as and skil ls for add ressing 31 –C EO fro mawest ern hosp ital for stereo typing. be in g aw ar e of bia ses and tendencies al co mpe ten ce tra ini ng ma y in cre ase whe n the re is 30 Sup port for cultur cl eare r evi dence of it s effect on patie nt care . Ac cordi ng to the HLC ” Rep ort of Fi nd in gs , “M ore rese arch is ne eded to eva luate the qu ality and saf ety im pact of di vers ity and cultu ral co mp etenc e trai nin g provide d to heal th care workers” (Reco mmen datio n 4-8).

32 CHA PTE R6: Acco mmo dating th e Nee ds of Spe cif ic Populations sh ould no t be a su bst itu te for gro up trai nin gs that give Pr ov idi ng Staf f with Educ ati onal Ma ter ials and Tool s st af f an op portu ni ty to inte ract and openly dis cus s cul - HL C stu dy hospi tals used self -st udy mat eri als and tools tu ra l di ver si ty issu es. to edu ca te staf f ab out C&L issue s. Res our ce books on dif - repo rt ed , an d a num ber of hos - fe rent cul tu re s we re often Ho spi ta ls can be tte r un de rstan d dif fere nt staf f pe rspe c- pita ls dev elo pe d visual aids such as car ds fo r st aff to use to ti ve s and possi bly identi fy othe r issue s that ne ed to be . As a me mber of leader ship co mm uni ca te wit h patients addr esse d th rou gh in-p ers on ses sio ns th at fac ilit ate staf f from , “We don’t nece s- a mi dwe ste rn hospital described te nt care di alogu es. Th e imp ortan ce of cultu ral ly compe at th e bed sid e 24 hou rs a day for sa ri ly ha ve an in ter preter exte nds beyo nd the li mi te d Engli sh prof icie nt (LEP) at io n so the re’s a lot of time ever y day of th e hospitaliz po pul ati on and can addr ess co mmu ni cation iss ues th at has to use his or her skil ls to tal k wi th that wh er e the nurse af fe ct po pul ati ons wi th physi cal di sabi li ti es . On e hos pi- You can do e ba sic da ily needs. pati en t [a nd ] com municat tal dev elo pe d ha nds -on ro le -p lay acti vi ti es to pr ovi de tha t ver y si mp ly through pict ure s, and yo u can show th em sta ff the op por tun it y to exp er ie nc e the per specti ve of [te xt] in thei r la ngua ge. . . . It’s ju st somet hing for da y-to - he ar ing- an d vi sio n-i mp ai re d pati ents . day to ge t by.” Whil e these types of car ds may be a rela - for st aff an d may fea tur e many ti vely in ex pe nsive re source Us ing Techno logy to Su pport Com mun icat ion of the is sues commonly nt ered by pat ients, such encou cal ai ds can be used to incr eas e the ef ficien cy Tec hnologi to ol s are far fr om exh aust iv e, only scr at ch ing the sur face of tel e- an d ef fic acy of inte rpret in g ser vi ces . Dual ha ndset and ma kin g the healt h ca re con - ind ivi du al pat ie nt issues enie nce of passi ng a phone pho nes ha ve red uced the inconv ver sa tion fai rly one -sided . As hospit als and their st aff use bac k and fo rt h bet we en pr ovi de r and pati ent or us in g the vari ous res ou rc es, the y mus t rememb er th at these are not sp eaker ph one fea ture durin g telep hon e interp reti ng lan - sub stit ut es for forma l langua ge tra ining and /or quality encou nte rs. One nor theas te rn ho spi ta l rep or ted us ing gua ge se rvi ce s. han ds -fre e hea ds et tec hn olog y, and a memb er of th ei r le ad - er shi p sai d, “We hav e ma de bro ad er and better use of a tio ns such as in tran ets hav e also provided On lin e applica ph one -ba sed transl ation ser vi ces ov er th e last five yea rs . We sim - new cha nnel for ho spita ls to dis sem inate in formation hav e beco me a li ttle more ade pt in using th ose ser vice s il ar to th at incl ude d in cu ltural res our ce bo ok s. One C&L th rough han ds -fr ee teleph on ic head set s. . . . Pre -adm is sion, serv ices staf f membe r fro m a midw este rn hosp ita l noted , “W e’ve tri ed to dir ect more and mo re staff to th e divers ity int ra ne t, . . . [whi ch provide s] re sourc es an d informat io n to the m. We ha ve a co upl e of links on th at site tha t give them imm ed ia te translat ion of written ma terial s as well. So, we’re it easy to use at the tr ying to keep it updated and make “They had a‘lunch-an d-le arn’ [sessi on] be dside . Th e in tr anet sit e has bee n a re all y excellen t tool last ye ar where pe ople came andput on be cau se so many pe op le are looking fo r so mething quic k.” he adph one sso [that ]the ycoul dn ’thear. “ [Physici ans] wou ldst and there and read you med ical instru ct ions and [ask you to] that stand-a Hosp ital s sho uld be aware lone se lf- st ud y repeat ba ck what they sa id. You would be ma teria ls ca n increa se the lik eli hood of ste re otyping, [like ], ‘Huh ?’...Or ,yo u[had to] put on given th at only generaliz ed des cri pti ons of various pop - these glasses so [that]yo ucou ld not see, ula tio ns and cultures may be avail able in re source books an dyo uwere supp osed to fill out amenu 31 or vi su al aids. Edu cati onal ma ter ia ls suc h as the se 32 [as adiab eti c]. ” –Hu man resource ssta ff from HLC Repo rt of Fin din gs cau tion s tha t “o nc e a pa ti en t’s race , cul tu re , 31 Th e awe stern hosp ital ine d, hos pi tal staff n have been determ ge, an d religio et hn ici ty , langua of the ten den cy tow ard ste re o- an d med ical sta ff sh ou ld be ma de aware ty ping in orde r to av oid ma kin g assu mp ti on s abo ut pa ti ents” (R ec om menda ti on 4-4). ”

33 CHA PT ER6: th e Need s of Spe ci fi c Popul ations Acco mmoda ting Crea ting an Envir onment tha tMeet s hi st ori es, an d pre -e xa minations can be done by ou r per - son nel who are wearing han ds-free se ts so they can do Specif ic Pat ient Needs ph ys ical exam in at io ns with pa tient s an d have telep honic tion s, In or der to meet the need s of diver se pat ien t popula to time. If yo u need someone in terp reta tion at the same hos pi tals are deve lo pin g or mo dify in g ex is ting servic es to breat he deep ly whi le you ex amine the so lid organ s in th e pro vi de saf e, qual it y ca re to the spe ci fi c popul ati ons they yo u can do th at and ha ve your hands available ab do men, se rv e. Th ese accom modati ons have invo lved alter ations an d do wha t yo u nee d to do. That type of tech nical help to va ri ous aspe ct s of th e hosp ita l’s physic al sp ace , pro - has be en very us efu l. ” gr ams , and serv ice s to cr ea te an envi ron ment th at is incl usiv e of all pati ents . e for pr ov iding inte rprete r One ca ve at to usi ng the te lephon - nonverbal misses ser vice s is th at th e int erpreter communi Enha ncin g the Hospi ta l’ s Phy sica l Sp ace Hos pit als are ca ti on bet we en the pa tient and pr ovid er. Hospi tals may rous efforts to cre ate a ph ys ical envi - unde rta kin g nume wa nt to de fi ne, thro ug h organization al policies or proce - ron ment that sup port s the div ers it y of their pa tie nt pop - 32 in ter - dure s, which sit uat ions are app ro pria te for tele phonic The physi cal en viro nment in cl udes ever ything ulat ion. pret in g an d which req ui re direct n [28]. interactio fr om th e lay out of wait ing areas an d wait in g rooms to na vi ga ti ona l si gna ge an d de co r. One mi dwest er n hospi - dis ta nce interp re ting Tech nology has als o enhanced tal discovered th at provi di ng cultur ally com petent care th rou gh the use of vide o med ical interpr etin g. The vid eo of th e hospi tal ’s en tire envi ron - requir es an as ses sment nt adds another tion to di sta nc e compone level of informa men t from the pa ti en t per sp ec ti ve . As di ver se pat ie nt interp re ting, as inte rpreters are able to better see non - po pul ati on s may co nta in gro up s othe r tha n LEP cated verba l beh avi or s co mmuni by pat ients and st aff . In pati ents , ho sp ital s sho uld co nsi de r all perspe ctives when hos pita ls , vi deo me di cal in te rpr eti ng has improved some pro vid ing ca re. the efficienc y of in-ho us e interp rete rs by eli mina ting tr avel tim e fro m one pati en t to the nex t. Vid eo medical ting se rvices provi ded by ext er nal vend ors can interpre al so allevi ate the demand for in- house int erp re te rs with - “We ’ve do ne ase ries of aud itsof ou rspa ce, obtai ned from nonverbal ou t sacr ifi ci ng the information wh ere pe op lejust go an dsi tinawai ting area cues. and see wh at hap pens. Or, [they] doavi sual “ assessmen t. If co un terto ps are reall y hi gh an dyou’ re si tting inawh eel chai r, ho w Note sonTe ch no logy accessi ble is that? So, the re’ sbeen avery Any technological upg rad es may co me with a co nce rted ef fort aroun dthe envi ronmen t. si za bl eprice tag so itmay be wort hwhile for hos - As wehave done remo del ing of pa tient care pit als to exper imen t an d pilot the use of the se uni ts, [and] aswe ’ve don eremo del ing of tech nologies to loo k at a cost-b ene fit ratio . ot he rsp aces, it’swith an eye towa rd how Alth ough each or ga niza tion is uniq ue, apossible wel comin gweare to all peopl e. ” pr oxy for this pr oce ss wo uld be to solicit and share inf orma tion withotherorga ni zations until –C&L services stafffro ma mor e robu st research ca n be con du cted in the midw este rn hospi tal fie ld.Hosp itals shou ld also con sider staff needs and an yan ticip atedbarr iers to using new tech - ” 33 no logy. While techn olog ies in inte rpr etin g are pr om ising, organiza tion s sho uld keep in min d Ethi cal th e AMA’s 32 In Impro vi ng Commu nicat ion — Imp rovin g Ca re, Fo rce Pr og ra m adv ises or gani zati ons to cr ea te “a phy sical envir onm ent tha titis no tthe tech nolo gy alon etha ten han ces tha t fa ci li tat es com mu ni cati on by fos te rin g a fe eli ng of welco me and care ,but rather the way itis us ed by hospital st af f co mfor t for ind iv idu als fro m com muni cati on-vul ne rabl e pop ul ati ons ” to bet ter co mmu nicate and meet patient needs. (Cont ent Ar ea 5a, Pe rforma nce Exp ectati on 1.0).

34 th e Nee ds of Spe cif ic Populations dating mmo Acco CHA PTE R6: Adap ti ng Serv ices to Ad dress Cultu ra l Beli efs Some An othe r significa nt com po nent of an incl us ive env ir on - hosp ita ls are alt er ing or ex pa nd ing exist in g ser vic es to me nt is th e pre sence of dire ction al sign age and ot her cr iti - 33 35 addr ess the cul tu ral be lief s of th eir pati ents. These typ es ca l pos tin gs in a for mat th at is appro priat e and access ible. Howe ver, ac hie vin g a patien t-fr ien dly en viron ment enco m- s ar e ma de on a case- by -case ba sis an d ca n- of adj ustment lit - passe s mo re than just havin g bil ingual sig nage; health no t al ways be planned , nor ca n the y be re flecte d in an erac y le vels sh ould als o be tak en int o ac co un t. As a memb er org an izati on’ s po li ci es an d pro ce dur es. Or ga ni za tio ns of lea de rs hi p from a west ern hos pit al remarked, “It’ s just shou ld make an eff ort to be re sp onsi ve to pa ti en ts’ be in g sen sitiv e to pe opl e in gen eral . . . . Hospitals are lik e cul tur al ne eds and prefere nc es. can ’t fin d [wh er e they need to ma zes to some peo ple .They to in ter - — it’s hard fo r them go ], even wit h great si gnage Wh ile some pra ctic es may re sul t in sign ific ant ch anges pr et som e sig ns. ”To me et bo th lit eracy and lan guage nee ds , to hospita l se rvi ces , oth er situa tio ns can be reso lve d fair ly 34 hos pit al s may co ns id er usi ng un iv ers al health ca re sym bo ls sim ply. A midw est er n hos pit al reloc at ed a fem al e Musl im or fo cus som e at te nti on on train ing th os e at initia l points pa ti ent to a di ffe rent unit to acc omm odat e her cultural of co ntac t, such as info rmatio n desk repr es entatives, to be pr ef ere nce for a female pro vi de r. At a no rtheas te rn hos - se nsi tive to and inclusive . of div er se patients pi ta l, the CEO dis cusse d how staf f foun d ways to show ity: th eir re sp ect fo r be li efs am on g th e Ch inese commun of an existing phy si cal Be yond red es igni ng the el ements “You know [h ow some] pe ople have a su pe rs ti ti on ma y also require environment an inclusive space, stru ctural [ab out ] the num ber 13? In th e Ch ine se cu ltu re, it is hospit al s ar e ma king ts to adjustmen add iti ons . Some [aro un d th e num be r] fou r, so we do no t put Chi ne se and staf f. As a acc om moda te the ne eds of both pa tients pati en ts on the fourt h flo or or do any thi ng wi th th e CEO fr om one no rthea st ern hospita l comment ed, “We numbe r fo ur. . . . Yo u have to be re spo nsive to th at sor t for ha ve actua lly ope ne d up a mo sque, whi ch is interesting of [cultu ra l be lie f].” d] wit h th e Imams a Lut hera n inst it uti on. . . . [We ] work[e in th e com muni ty and with our phy si ci ans. We have quite a numb er of ph ys ic ian s [and pa tien ts] who are Muslim, and to becaus e the y need ed to pray du rin g the day, there needed be a sp ot to do it .” This pra cti ce ref le ct s a structural modi - “You have to un de rst and theva lues fica tion targe ted to a spe cific populat ion and illustrates of the cul ture .Th epredomi nan tvalue nity lea ders to im prove the im por tance of en gaging commu for theHisp ani ccu lture isfamil yand “ ho spi tal serv ice s fo r patients and sta ff. relat ion sh ips. ...Th eItalians [inthi sarea] are the sa me way. It iscri tica ltha tweprovi de As hospit al s con side r change s to th eir ph ysic al spa ce, dat a an envi ronme nt to accommo dat ethat. co lle cti on will play a key rol e in understa nding the needs Our Women ’s Ce nte rha shu ge rooms. ... It’s not hi ng unusu alif there is amother of pa tient po pula tio ns an d/ or st aff , and as th e previous in labor ...[and ]there mi ght be 15-20 exa mpl e ill ustra tes , collabor ation ma y play a rol e in peo pl e[inthe roo m]. ...It is crit ical that des ig nin g and imple me nt ing so lut ion s. Understan ding we accommod at e[cu ltural val ues]. ” to th e unde rly ing va lues of pati ents’ culture s is essential pro vid ing sa fe, qua lity care. –A membe rof lead ershi p from awe stern hosp ital 33 As require izati on s mus t d by CLAS Standard 7, “Health care organ 34 mak e ava ila ble easily un dersto od pa ti ent-rel ate d ma teri als and pos t sig- ” nage in the la ng uag es of th e co mm on ly enc oun tered gro up s and/ or e area.” group s re pre sent ed in the servic 35 The end s th at “ho sp ita ls shoul d take recomm HL C Rep ort of Findin gs 34 The Habla mos Juntos ati on on Found proj ec t of th e Robe rt Wood Johns adv ant ag e of the int ernal and exte rnal resour ce s avail able to edu ca te deve lop ed and test ed a set of unive rsal hea lth ca re symbol s th at is avai l- them on cu lt ur al be liefs th ey may encou nte r” (R ec omme nd ation 4-3) . abl e at www.h ablamo sju nto s.org.

35 CHA PT ER6: ting ations Acco mmoda th e Need s of Spe ci fi c Popul Helping Pa tient sManage Their Car e As a hum an res ou rces st aff me mbe r fr om a midwe st ern e po pula - are bette r servin g divers An oth er way hospitals hos pita l de sc rib ed, “We ha d a pa tien t who wore a [cult ur - tio ns is by of ferin g se rv ic es that allow patients to more ea s- While ally symbo lic br acelet ,] and she had to have surgery. 3 6 ily na vigate the health care sy stem. Hos pitals are al so of to the western we were try ing to be attentive ph ilosophy g to hel p pro vi di ng pa tie nt s wi th edu ca ti on and trainin ine , we di dn ’t realiz e that the re we re other medic thin gs them take res po ns ibi li ty an d advoca te for the ir own hea lth. go ing on . Som eone real ized later that they co uld pu t tape ove r the [bra cel et, ] in the [o perating room] to ma intain Patien t navig atio n Na vi gati ng the Healt h Car e Sys tem for all sanit ati on bu t also make th e pl ace mor e welc oming and del ays to progr ams are de si gn ed to el im in at e barriers ” Alth ough peo ple wh o have different pra ctices. this reso - diag no sis an d tr eatme nt thro ug h one -on- one cont act [29 ]. it to ok initi ative on the part of hospi - lut io n se ems simple, Pa tie nt na vig at ors ma y assi st pat ients with nu me rou s iss ues , tal st aff to re sp ec t the patie nt’s belie fs and fi nd an acc eptable ranging fr om in sura nc e to log ist ics (e. g., app ointme nt ly ben efic ial . com pro mis e that was mutual sch edu ling , tran sp or tat io n) to cu ltu ra l be li efs to educ ati on . Na vig at ors ar e typi cal ly membe rs of the co mmun ity ser ved, Ot her ho spitals mentioned adapting the ir foo d service ar e kn owle dgea ble ab ou t th e he alth care sys te m, ca n com - pr ogra ms , suc h as developing a halal ki tch en and me nu or mu nica te eff ec tiv el y with pat ient s and thei r fa mil ies, and blessed by loc al re lig io us leaders. kitchen ha ving their co llab ora te wi th exte rn al pa rtners to coo rdi na te follow-u p Deve lopin g men us th at are more at tuned to the cul tures of an d suppor t servi ce s [30]. a foo d preferenc e issue. pa tie nt pop ulati ons is not solely may pl ay a rol e in specific tra dit io ns, as on e CE O Food One we st ern ho sp ital used a pati ent na vi gato r mode l tar - from noted : “W e had a sizable a nor the as tern hospital ge te d to immig rant po pula ti ons tha t int eg ra tes cul tural who wer e deliver in g their Ko re an popu latio n of women med iat io n, co mm uni ty engag ement , pat ient naviga tion , here , and then all of a sud den , they dis appeared. chi ldren eme nt , in terp ret ing , an d prov isi on of ca re. cas e manag cu ltu re, the birth of th e Why is th at? Wel l, in the Korean chi ld and the care of the mo ther necess it at e the serv ing of seaweed soup to th e mother post-d eli ver y. Who would kn ow th at un les s you figured out wh y they were not co m- in g ba ck? So we le arn ed the hard way that . . . serving the “We ha dan orga npro curemen t[issue, se aweed e so up wa s [part of] their cul ture .” This exampl in whi ch ]thespi ritual lea der coul dnot leave the em pha sizes the nee d to lear n abo ut and bet ter underst and room. [Thepati ent ’scul ture be lie ves] theso ul “ the co mm un ity serv ed . If this organ iza tio n ha d not taken doe sn ’tde part with out them. ...but [it’s] ve ry nity, it th e init ia tiv e to re ach out to the Ko rean commu unu su al to ha ve anybod yelse in theop erat ing to wou ld ha ve not dis cov ered a simpl e acc ommod ation room duri ng tha tpart icul ar proced ure. But al l wi th thi s popula tio n. rec onnect therightpe opl ewere not ified ,and all the arran gemen ts were made ,and we we re able Ho spit al s hav e also found the need to ad apt direc t pa tient to dotha t, toaccommoda te them, beca use we ca re se rvice s. In or de r to mee t the nee ds of th eir Soma li kn ew how impo rtan titwa sforthe fami ly and fr om a mi dwestern hospit al populat ion, on e CEO everyon eelse involve d.” des crib ed the nee d to add to thei r wo rkforc e, “Fo r the –A me mber of leadersh ipfrom ics] Som ali [p opula tion,] we have a do ula in our [obstetr ami dw este rn hospit al have a very differen dep ar tm ent. Somalis t perspective abou t 35 gy nec olo gic and reprod uctive health tha n [Wes tern medi - ” cine ]. [Th e doula ] is kind of lik e an ad voc ate in labor — Impr ovi ng Commu advi se s organ ng Ca re ni cat ion — Improvi 36 iz ati ons to n — no t to be a physicia to know som eo ne who ’s tr ained hav e “p ro gr ams to he lp commu nic atio n-vuln er able pop ul ati on s na vigate ext en de r bu t [r ath er ] a pa tient extend er.” the he al th car e sys tem to ap pr op ri ate ly us e he alth car e resou rce s” (Cont ent Ar ea 5, Perfor man ce Exp ectatio n 2.0).

36 Acco CHA PTE R6: mmo dating th e Nee ds of Spe cif ic Populations rec ei ve some tra ining and educa tion abou t how to care fo r A mem ber of the le ad ershi p fr om the same hospita l said, the bab y. She was no t abl e to com e ba ck becau se of thi s “[T]h cas e es e navigat ors have a cap aci ty to do complex cu ltur al pra ct ice — to re st fo r 30 days — so [t he husba nd] ma nag em en t, as we ll as ed uca tio n [a nd] some pu bli c heal th was goi ng to com e in her plac e. Ou r pr ac tice was that mo m s, go out wor k, beca use they ca n brid ge cl inic al en counter co me s in an d rec ei ves tha t ed uca tion, so we rea lize d that to the co mm unit y, and talk abo ut th e impl ica tions fo r the we need ed to . . . re eval uate our own pra cti ces .” Th e or gan - com muni ties — kind of a pu bli c he alt h veh icle.” However, iz at ion su bse quent ly mo di fi ed th eir pos t-ch ildbir th tra in- ho spit al s are cau ti oned that the im plem enta tion of a pati ent in g to eng age th e fat her, th us ac comm odat ing the mother’s naviga tor program iz at io ns to define may re qu ire organ ne ed to rest for the allotted time per iod fol lowi ng la bo r. rs an d pro - t navigato bo un dar ies bet we en the roles of patien fes si onal int erpr et ers. If navi ga to rs wil l be us ed to int er pr et Usi ng Te chn ology in Pa tie nt Instructi on and dur in g medi cal enc oun ter s, th ey sho ul d be as ses sed fo r So me hosp itals have use d te ch nology to dis- Ed ucati on la ngua ge. lan gua ge pro ficiency in Engl ish an d the target tion, incl ud ing onl ine ed uc at ion via tribu te pati ent educa stre am ing vid eo techn olo gy in sig n lang uag e for deaf and Pr ov idin g Pat ient Edu cation an d Tr ai ning Pat ient s ha rd of heari ng pati ents as we ll as lan guage tran slat ion mus t have the ap pr opria te edu cat io n and tr ai ning to so ft wa re to pro vi de educ ati onal and di sc har ge mater ia ls inf or med decisions, in, and act ivel y par ti cipate make 37 in pati ents ’ pri ma ry langu age s. Hospitals have use d the Hospi tals emp loye d sev eral prac tice s man ag e th ei r care. in ter net or an org aniz ati ona l in trane t to creat e pat ien t Spanish to educat e pati ents in th ei r pr imar y language. ti on materi als in mu lti ple lan gu ag es . At a west ern educa in terp re te rs hav e spe cifica ll y bee n us ed in obs tet rics (OB) ho sp ita l, huma n re so urc es staf f di scus sed the ir us e of to assist pati ents wi th and ne on atal int ens ive car e units elec tro ni c patie nt edu cati on so ftware to crea te docu- dis charg e inst ru ct ions , whi ch re sult ed in dec re ase d rev is - si de , me nt s tha t mee t lan gua ge ne eds, “[F]o r the nursing at it s to the eme rge ncy ro om. Accor ding to the leadership uter ] prog ram. [It has] we have a patie nt educa ti on [comp a west er n hos pita l, “[We ] reco gnized the re [were] a larg e wh ate ve r to pic you wan t to te ach to yo ur patie nt to take er of mom s and babi es re turni ng to the ho sp ital numb hom e and to rea d. It comes pr ed omi na tely in Eng lish aft er dis char ge . In invest igat ing that, [we] realiz ed that and Sp ani sh. . . . Th ere ar e up to ten lan guages provide d th e pr ob lem was that the y were n’t under st andi ng the for ce rta in to pic s.” with. . . . info rmati on that the y were be ing se nt home [No w] if you go up to OB, you wi ll fi nd ev erything yo u can po ss ib ly ima gine . Inf orma ti on ca n be communicated cor re ctl y so th at [n ew parent s] can lea ve th e ho spital an d kn ow ho w to ca re for tha t bab y an d kno w how to care for the msel ve s. . . .The re was jus t an abso lute decrease in the er of re turns we had of new mom s and babie s com - numb “One of theprogra ms we ha ve [includes] sol ut ion to wh at cou ld ju st tu rn ing back. It was a simple ca se ma nage rs that go into theco mmunit y out to be a dis as ter if [pat ie nt s] don ’t have the right info.” and are asparti cula rly whe re wehave “ non-Eng lish sp eaki ng ind ivid ual sand are needs to mee t bot h the educ ation al and cultural In an effort real ly ca se finders/ case mana gers, where of th e pa tient po pul ation, hospitals may als o alter how they they can wo rk withthose po pula tions and ti on to accoun t for tr aditi onal customs. A pro vid e educa en coura ge the mtose ek ca re whe nneeded.” me mber of lea dership fro m a nor th eas tern hospit al –C EO from awest ern hospi tal 36 had been dis - described , “[ Afte r chi ldbirth ,] the mother wa s fo r her to come ch ar ged . Wh at wa s needed ba ck and ” rds requ ire tha t pati ents rec ei ve “ed uca ti on ion standa 37 Joi nt Commiss and trai ni ng specifi c to th e patien t’ s needs and as app rop ri ate to the care, trea tme nt, and servic es provided.”

37 CHA PT ER6: th e Need s of Spe ci fi c Popul ations Acco mmoda ting cul tura l ne eds of th e pati ents th ey serv e. In som e instanc es, is a Ho spi tals sh ould reme mb er tha t alt ho ug h tech nology hos pital s de signed cult urally cent ered prog ra ms to he lp cha nnel to con vey informa - mor e con venie nt or eff icient bri dge cu lt ura l barrie rs in the und ersta nd ing of hea lt h and that will tio n, it is the qua li ty of the messag e an d materials heal ing. For exa mpl e, one wes tern hos pita l faced chal leng es are whether ulti ma tely de ter mine the ne ed s of patients whe n re conci li ng idea s betwe en pra ctices in Wester n me d- shou ld be ing met . With on li ne tr anslat io n tools, ho spitals ici ne and the trad it iona l healing pra cti ces of the Am eri can e pro - rem ind th eir staff that lang ua ge trans la tion softwar Indi an po pula tio n th ey ser ve. A C&L se rvi ces staf f mem - ha ve vi des lit eral tran slati ons , an d therefore , they should ber describ ed , “I n Nati ve med icine ther e’s no diab etes. The ed to wr itt en pol ic ies abo ut the editing proce ss th at is requir 38 illnes s a patie nt carrie s ha s anot her diag nosi s in Nativ e With ou t prof ess ion al ver ify th e accu racy of the translati on. medi ci ne . . . so th en as a pat ient , you wil l ha ve two ill - , the tr anslat ors to ed it ele ct ronic ally tra nsl at ed docu ments rn me di cine , and ano the r ne sse s, [one dia gno sed by Weste be con - da nger is very rea l tha t inco rrect infor matio n could di agno sed by Nati ve medic in e]. . . .Th e prac tition er, physi - ve yed to pat ie nt s, compr omising an d care. pat ien t safety ci an, and nu rse s ha ve to ha ve so me gener al under stand in g ab ou t the cu ltu ral bel ie f and the legal issu es so tha t the y Note sonLan gua ge Tra nsl ati on te ach [pat ient s] acco rd ing ly — or prov ide me di cati ons So ftwa re acc or dingl y.” Thi s hosp it al formal ly est abli sh ed a Nat iv e Org aniza tion ssho uld be awa re that altho ugh lan - me dic ine prog ra m and a Tra ditio na l Hea ling Commi tt ee gu age tran slation softwa re and online tra nslation int o tha t wo rke d to int egra te tra diti ona l hea li ng pra ctices tool scan ma ke some proc es ses more efficie nt, thes ereso urces may only pro vid einform atio nin th e West ern medi ci ne prac ti ced in the hos pital to be tter on e di rec tio n, su ch as tools that only pro vide ty. se rve their Ame rican Indi an communi ins truc tion. Wh en such progra ms are used alone, ther eisno way for he alt hcare providers to asce r- In ot her case s, cu ltura lly ce nte red pr ogra ms provi de d se rv - tain the lev el of pa tien tund erstand ing orrespond ice s that bett er reco gni zed the dist inct need s of vari ous to pat ient con ce rnsan dque stio ns. Ho sp itals ma y grou ps. On e mi dwest ern ho spi tal de ve lope d a te le-p sych i- co nsi der sup pl em enting the use of electron ically at ry pr og ram to be tte r serve the nee ds of the ir dea f an d tra nslat ed patien teduca tion do cume nts with pr o- har d of he aring pat ient s. A C&L serv ic es st aff me mb er fessio nal inter preters tofaci litat eco mmun icati on poi nt ed out , “We hav e a psycho logi st /p sy chia tri st who be twee npa tien ts and pro vid ers. Esta bl ish ingCent ra lized Programs tha tMee tSpe cific Nee ds ofLarge Po pul atio ns ca nt For la rg e pop ul at ions tha t ma y co mpr is e a signifi “Inpsychia try, wehave cult ural ly focu sed of pati ents, it may be neces sary to deve lo p cen - number un its—Sp anish -focu sed, ga y-f ocu sed , an or gani zati on to implement pro gr ams within tr alized Asi an -focuse d. We have had wa ivers on “ se rvices syst em-wide that address sp eci fic pat ient needs . po si tionsthat woul drequi re ape rso ntogo typ es of pro gr ams are often These to cre at ed in re sponse thro ug hspeci fic cla sses befo re bein ghired diverse cu ltur al and reli gi ous needs. for [on eof these ]posi tio ns. Thi smo del in psych iatry has worked well ,[an d] it isabi g at tra cto rforst af ftowork here .” Hos pitals ha ve ms De velopi ng Cu lt ur ally Centered Progra 37 fo rma lize d progr ams bu il t aro und th e uni que deve loped –CEO fro mawe stern hosp ital 38 As recommende d by Improving Communicat ion — Improving , Care organiza ensure ti ons should that “tran slatio ns from En gli sh are Area 5b, and chec ked fo r acc ura cy” (Co ntent in dep end ently eva luated ” 8.1). Per forma nce Expe ctation

38 th e Nee ds of Spe cif ic Populations dating mmo Acco CHA PTE R6: tatio n serv ices to pa tient s, bu t offer guid an ce as a group on spe aks si gn lan guag e and throu gh vide o stre am ing gives how the ho spital can engage th eir communi ty. appo in tments er . . . . to peop le ove r the ir home comput [T hey provi de] me nta l heal th and behav ioral health Spi rit ua lly or cu ltu ra ll y cent ered comm ittees can play an se ssi ons [a nd] co nsul ts.” impo rtant role in the dev elo pmen t of ce ntra li ze d pro gra ms. In addi tion to th e use of focus gro ups, as des crib ed in the Sim ilar ly, a weste rn hosp ital cre ate d a cu lturally focus ed Chapte r 5: Coll ectin g and Using Dat a to Impr ov e Serv ic es , mo date s se veral populations ps yc hiatr ic unit that accom these com mi tt ee s ca n info rm the deve lo pm ent and imple - in the ir service com munit y. Cu ltu ra lly cen tered progr ams menta tion of such cent ra liz ed programs. and cul - need to be suppor ted by targ eted re cr uit ment tural co mp ete nc y traini ng, and the cul tural compet enc y st aff comp le tes is both ong o- trai ni ng that this pro gram’s Conclu sions ing and ev alua ted for effi cacy. As de scri be d by a hu man Accom modati ons targe ted to th e ne eds of sp ec if ic popul a- res ource s st aff memb er, “We have ce rt ai n thin gs suc h as tion s evo lve as hospita ls sea rch fo r solu tio ns to the chal - that te nc y test ing . We require man dato ry cult ural compe len ges of pr ovi ding ca re to th ei r di ver se pat ie nts .To ensur e all of ou r staff hav e at le ast one train ing . . . and mo nthly or ga niza tions mee t cha ngi ng sta ff and pati ent ne eds, the un it- ba sed upd ate s. I thi nk wh ere [w e se e result s] is dev el opme nt of servi ces and ac ti vi tie s ta il or ed for spec ific s.” aro un d pati ent rel ati onship the populatio ns sh ou ld be a con tinu ou s pro ce ss . While practic es outlin ed in th is cha pte r sho w po sit iv e st eps ng Relig ious or Sp irit ua lly Cen tered Programs Developi tow ard the deli very of cultu ra lly an d lin gui stic ally appro - Alo ng with meeti ng the cul tu ral ne ed s of pat ient s, hospi - pri at e ca re, th ey als o in dic ate the comp li cated real ity of th e ta ls hav e est ab lished progr am s to mee t var iou s reli gious long ro ad ah ead . Alth ough kn ow le dge, fiel d experien ce, 39 A hu man re sou rc es staf f and sp iri tu al need s of patien ts. and tec hn olo gy have imp ro ve d th e de li ver y of C& L serv - me mber from a we ste rn ho spi tal no te d, “On e thing that ice s, hos pi ta ls need to cons ide r th e bala nce be twee n con- ha s bee n iden ti fie d on the pati ent side was mo re su ppor t, ve nie nce, cost, pa ti en t sa fety , and qua lit y. Ch apte r 8 a year ago, spirit ually . . . [The hosp ital ] starte d a program inc lu de s a self -a sse ssm ent too l hospita ls and oth er he alth and th e emp lo yees are vol unt ee rin g to give the ir skills to car e org an izati on s can use to eva lua te the ir cur rent C& L he lp . Thirty -fi ve pe rce nt of our pa ti en ts are Catholic , so ser vic es with respect to th e sp eci fi c pop ula ti ons they se rve . to meet that ne ed. Whe n [pat ients] are in the we wanted hospit cted wit h their to be conne al , [t hey feel] a need fa ith . What we fo un d is th at we hav e far more employe es wi ll ing to he lp wit h re li gions [i n ad dit io n to Cat hol icism ]. “We hav eaSpiritual Ca re Adv isory 60 volu nt ee rs] th ro ugh a six- we ek train - We to ok [these Co mm ittee co mpr ise dofco mm unitycl ergy. ing on prayi ng in other rel ig io ns.” A nort heast ern hos pi - The loca lImamofthe mo squein [thene ighbo ring “ ta l addre sse d the re li gio us needs of their pop ulati on by com munity] isonit.Th epriestfromtheCat ho lic chi ld rem em brance servi ces to expand ing thei r annual chu rch next doo rison it...We hav earabb i incl ude fo ur differen t re ligi ons. from atemplein[aneigh bor ing co mmu nity] invo lve daswell,soit is awho le cross -sect ion of pe ople—thefirst co un cil for[th eCh ur chof Twen ty perc en t of hospitals repo rt ed th at they ha d devel - Jes us Ch rist of Latte r-Da ySa ints]is al so on it. pr ogra ms co mprised of lea ders oped inte rfai th ch apl aincy The yareou rad vi so ryco mmitte e; [and ]the ytalk a var iety of differe In so me nt re li gi ous gr oups. from 38 withus ev er yyea rabou tho wto prom ote our ce s, the se rel igious instan lead ers no t only prov ide cons ul - programsinthecom mun ity. ” g Care Imp rov ing Com mun ication — Improvin 39 advis es that “th e organi za- –C&L service sstafffrom of com mu nic atio n an d educ ation al eve nts [be] sensi - tion ’s sch eduling awest ern hospi tal tiv e to re lev ant reli gi ou s an d cultu ral obs erv an ces” (Co nten t Ar ea 5a, Perform ance Exp ec ta tion 6.0). ”

39 CHA PT ER6: Acco mmoda ations ting th e Need s of Spe ci fi c Popul servi ces and res ources As org aniza tio ns create for specific will likely in clude elements of po pula tio ns, these initiatives Chapt Chapter 5: Collecting er 4: Build ing a Fo und ation, an d Usi ng Data to Impr ove Serv ic es, and Chapte r 7: “We have ha dto mod ify some of ou r and Ext erna l Co ll aborations. As a Esta bl is hing Internal pol ici eswithrespect to rel igiou spre fere nces. r of C& L servi ces from hospit al a mi dwestern membe We have apopul at ion of Jeh ovah’ s des cri bed , “[T he doul a progra m] came ou t of dia logue wit h “ Witnesses whouse ou rfacil ityand who in n fr om the community wome that we were able to bring do not belie ve inbl oodtran sfusi ons [du ring] s [and ] our birth prac - [t o] ta lk abo ut th eir bi rth practice su rge ry, so ourmed ical st af fhave creat ed ti ce s. . . . We had a seri es of three lunc heo ns . We so me polici esfor bloodle ss su rgerie swi ththe li te ra lly sen t van s out to go pi ck wo men up an d br ing th em Je ho va h’ sWitness lea dershi pwithi nthe as that . her e to have a dial ogue. It was as informal co mmuni ty tomake cert ain that we ed] int o the doula It [d evelop program that we [now] have.” are co nsi st en twiththe gui del ines that can con - of ea ch theme As this exam ple sh ows, elements the yha ve se tup.” ate tri but e to th e devel opment of prog rams tha t accommod –CEO from awest ern hospit al popul th e ne eds of specific ations. ” 39

40 CHAPTE R7: Int erna l and Est ablis hing Ext er nal Co ll abo ratio ns sity Br ingi ng Sta keh ol de rs Together Beyond the Diver ss those tha t bring toget her Col la bo ra tiv e prac tic es encompa While bring ing toget her a diver se com mittee Co mmi ttee s, organ izatio ns, pr oviders , and indi - mul ti pl e depa rtment or ta sk fo rce is im port ant, inter depar tm ental collaborat ion s vi dua ls to ach ieve objectiv es rel ated to cul tur ally and lin - ” shou ld not be ex cl us iv e to sp ec ialized “d iversity groups. guis ti cal ly appr opriat e care . Co ll abo rat ive par tnershi ps, The se ty pes of colla bor ations could be uti lized to im ple - ca n pro vid e a cond ui t fo r un der - both int er nal an d ext ernal, men t an y of th e practi ce s ou tli ne d in th e pre vious chapter s. ta ki ng th e prac tic es ou tli ne d in Chap te r 4: Build ing a By gat he ri ng a div erse gro up of st akeho ld ers to wor k Foundat io n, Chap ter 5: Col le ct ing and Usi ng Da ta to to geth er on proj ec ts and tasks rela ted to cultur al compe - ting the Impr ove Serv ice s, an d Chap te r 6: Acco mmoda te nce , the va ry ing pe rspe ct ives tha t th is type of grou p can Nee ds of Spec ific Popul ation s. Co llabo rat ions ca n help hos - gi ve wil l he lp gui de org aniza tion s thro ugh variou s st eps in pi tal s eng age thei r co mm uni ty, sh are inf ormat io n and s. Fir st, in def in in g is sues , they can pro vi de ins igh t the proces res our ces, and impro ve the car e they pro vide. and iden tif y specif ic needs to be add ressed. Sec ond , they can gu id e im plem ent ati on as there ma y be ex isti ng resou rce s Wor ki ng To ge ther with inth eHospital wit hi n ea ch depa rt ment that can be po oled toget he r or sh oul d be Wit hin each hospit al, di ff ere nt stake ho lders e. Thir d, they exi sti ng proces ses tha t ca n se rv e as a te mplat brou ght to ge th er to devel op , impl eme nt, eval uat e, and wi ll pl ay an imp or tant ro le in pilo t te st ing , ev aluat ing, an d imp rov e in iti at ives aimed at meet ing the ne ed s of diver se 40 pr ogram s and mat eria ls . pr ov idi ng fe ed bac k for re fining g any of th e Fo r th is rea son , whe n implementin patie nt s. Havi ng feedba ck from mult iple gro up s at a pilo t st age may prac ti ces ou tli ne d in the pr evious cha pters , di ver se indi - help refin e pro cess es, ident ify any are as that re qui re tailor - vidual s acr oss the orga niz at io n sho uld be invo lved, repr e- ing , an d reve al any cr iti cal gap s or laggi ng proc ess es . Des pite nt de part me nt s, po sit io ns, sent in g a range of differe - th e benef it s that thes e ty pes of int erdep ar tme ntal collabo nic bac kgr ound s, etc. pro fe ss ion al leve ls, racial/eth ra ti on s can brin g, they do not com e without their chal - de par tment s, le nge s. Brin gi ng toget her su ch var ying Est abl is hin g a Cultu ral Diver Inv olvi ng sity Co mmi ttee persp ect iv es, pe rson ali ti es , and cult ure s ca n ca use poi nt s of sta ff fr om across the organizatio n th ro ugh ou t th e de ve lop- di sag re em en t to su rfa ce, which may ge nera te tens ion . ment an d impl eme ntatio n of cul tura ll y co mp etent ca re is How ever , as co nt ent ious as these disc ussi ons may be come , essent ial to he lping identi fy al l th e need s to be addre sse d the se th ey may also he lp allev ia te existi ng tensio ns among an d to pr ovide ne eds. fee db ack on so lutio ns to meet those Alo ng th ese li ne s, among the most commo n pra ct ice s Bring ing Diver se Stak eholders rep ort ed by part icipa ting ho spi ta ls is the es ta bli shme nt of Together to Form aHigh-Level admi ni stra - a Cul tur al Div ers ity Com mitt ee comprising Tas kFor ce So me of th ese com - tion , ma na ge ment , and employees. Th e pr actice of bringing div er se sta kehold ers ty or rs of the communi mitt ees al so inc lud ed membe toge therca naddanot her level tothe ide aofthe grou ps are oft en ta sked with pro - pati en t pop ulat ion. These high -leve l task force intr oduc ed in Cha pter 4: men tors hip , educa tion, inform viding and ation sharing, Bui ldi ngaFou nda tion. The impo rtanc eofthetask oth er ac tivi ti es re late d to offe ri ng cul tu ra l and la ngu ag e force de scr ibe dinch ap ter 4isthat it ischa rged (C&L ) ser vic es. wit htheresp onsibility of driv ing cultura lcompe- tence. The Cu ltural Diver sity Com mitte e br ings icat ion — Improvin sugges ts , “Re gul ar eval ua- g Care Im pr ovin g Commun 40 tog ether div er sestak ehol der sfrom thr oughout the ti on s include tal kin g to workfo rce mem bers , com mu ni ty li ai so ns and organiza tio n to discus s and implem ent C& L- in divi duals from comm un ic ation -vu lne rabl e popu la tions about both 40 izatio n’ s com muni cati on pro- po siti ve and ne ga ti ve asp ects of the organ related initia tive s. Thes e two pr acti ce s ar e no t gr ams and stra te gies ” an d “the organ ization res pon ds to the re sults of mu tually excl usive. Ideally , a C&L- related task ev al uati ons by hav in g le aders , wo rkfo rce mem bers commun ity mem - wor k toge the r to ns it serves bers , and indiv id uals from th e pop ulatio force orco mmitt eewoul dbecompris ed of di ver se, de vel op solut ion s an d mak e ch an ges to plan s, pol ici es, proced ur es and mu lti disciplin arystak eholders and hold thepowe r ed ucat iona l prog rams” (C onten t Area 6, Pe rf orm an ce Expe ctati ons 1.2 andresponsibility to ov ers ee and dri veinitia tiv es. an d 8.0).

41 CHA PT ER7: Internal and Ext ernal Collaborat ions Establ ishing ver, sh ar in g exi stin g mat eria ls ca n al so req uir e ov er - Howe , gro up s as th ey have an opportu nit y to vo ice their opinions co mi ng any organizati onal “red tap e” th at may pr eve nt a co mmon goal. he ar fr om ot her s, an d wor k toward th is ty pe of co ll abo rati on. Addi ti onall y, alth ough hos pi - ta ls may be able to co nt ri bu te to a common poo l of Bu ildin gBrid ges with Ot he rHospitals e in a resour ce s tha t me et seve ral need s and are availabl or hea lth Ext ernal coll abo rat io ns — with ot her ho spitals 41 va rie ty of lang uag es, th ere wi ll sti ll be gap s, an d exist ing As hos pitals ca re or ga nizati ons — are equally impor tan t. ma te ria ls ma y no t be ade qu at e. fi nd ways to shar e th eir re source s wit h each oth er, they address may be able to better chal len ges such as limited her Pool in g Re sou rce s Toget Bri ng in g to geth er the and new materials res ou rces and hi gh costs for dev eloping res our ce s of mu lti ple hospit als to cr eate new mat er ial s tha t pr ogra ms. Re sou rc es and pr ograms tha t ma y ben efit from mee t the ne eds of div erse pa tient pop ula tion s is on e pote n- coll abo rati on incl ude staff training e, in cultu ral competenc tia l wa y to fil l pe rs is ten t gaps in ex isti ng mat eria ls . One and writte inter pre ter ser vic es, signage n ma terials avai lable mid we stern hosp ital colla bor at ed wi th a gr oup of ar ea hos - to pat ient s wh o speak in mult iple langu age s, and res ources pita ls to prod uce a se t of tran sl ate d mat er ials for use am ong l. langu ag es not commonly by the hospita encountered th e grou p. As a me mbe r of le ade rsh ip from this hosp ital , “[Th e] hosp it als all tog eth er recei ve d grant fundi ng and Sha ri ng Ex isti ng Re sour ces Many hos pita ls around th e de velo ped a web sit e th at is acc ess ible to all hos pital s [and with simi lar needs cou ntr y provi de car e to patients and face whi ch] has tr an slate d mat erials in mu lt iple lan guag es on all cu ltu ral ly an d linguisti com mo n ch allenges in pr oviding - of the bas ic he alth car e needs .”This hos pital als o repo rt ed Whil e each cal ly appr opri ate ca re to divers e popula tions. ta king pa rt in a col labo rative to create a cult ural com pe- hos pit al is uni qu e, they may sha re a co mmon need for te nc y inde x that addre ss es th e healt h care nee ds of 50 or 60 reso urc es, wh ich ca n bring to avoid ns together organizatio ethn ic gro ups in additio n to 25 or 30 cultu ral bel ief sys- “r einve nti ng the wheel” eac h ti me th ey take on C&L- te ms . The inde x pro vide s lin ks to tr an slatio n servic es and rel at ed ac ti vit ies. In some resources sha ring existing cases, re sou rces for pat ient he alth info rm atio n and edu cation can he lp reso lve issues fina nces , and sta ff. to time, related mat eria ls . Sin ce it s in itia l de ve lo pm ent, this par ticul ar hos - pita l has post ed this in de x on the ir in tran et. Fo r examp le, as pa rt of a gra nt they receiv ed, on e western hos pita l re por ted cr eating a web site for sharing infor ma - tion abo ut the differen t cul tures that are co mm on to their ge og raphi cal ar ea . As the CEO of the ho spi tal co mmente d, “We ca n ge t infor ma tio n [about] a va riety of patien t pop - it to [staff ] in a way that they under ula tio ns and present - sta nd. ” Wh il e the deve lopme nt of thi s web site is wor th “We are pa rt of aloca lco llabo rative, whe re is ment io nin g, what is more int eresting abo ut this example si xor se ve ndifferent he alt hca re syst ems that the organi zati on took this pr oj ect a step fu rther by have come tog eth erand said ,‘We don ’t “ sh ar in g it with oth er ho spitals that serv e simi lar com mu - all nee dto tra nsla te all ofour diab eti cand ni tie s. Si nce it s deve lopment, th is web site has been used by edu cat ioninf ormat ion into these six or se ven y and co ntinu es to receive ot her hosp it als acro ss the countr lan gua ge s. Wh ydon’t yo utake on doi ng half ofthose ,and we’ lldo hal fof tho se, and let’s suppo this way , rt from grant funding. By sh arin g res ources take ou rletterhea doff ofthat informat ion. ’ gaps in their own ho spi tals ma y find ne w methods of filling We can use that info rmati on across , th is ty pe of sha ring mat er ials and prog ra ms. Al ternatively 41 the syste m.” s they do not ha ve may al so help ho spit als devel op material th e res our ces to pro duce on their ow n. –Huma nresource ssta ff fro m ami dwe stern ho spit al gs 41 Recomm th is idea : supports en dati on 4-3 from the HLC Re por t of Findin “Ho spital s shou ld take advan ta ge of the inter nal and exter nal re sour ces .” av ai lab le to edu cate them on cul tu ral be li efs th ey ma y encounter ”

42 Estab CHA PTE R7: lishing In tern al an d Ex tern al Col labor ations the rese arch fr amew or k sug gest s that “in hos pit als tha t are By poo ling reso urces to creat e mat er ial s in this way, hos - l teaching progra ms (s uch affil iate d wit h he al th pr of essiona be tte r to ol s that they ca n all pita ls are esse nt iall y creating s, and sch ools of pub lic s, nur sing school as med ic al school re so urces sta ff member not ed, “[By use . As a human hea lth), ther e is an eff or t to int er act wi th the te achin g pr o- we can mak e sure that th e informa worki ng to gether,] - gra m to sha re infor mat ion about pr ov id ing ser vices to meet ti on is ac cur ate, but we can [al so ] be mo re effective with the di ve rse cult ur al an d li ng ui st ic ne eds of pati ent s” [3]. th e in fo rmati on we have.” This type of op por tunit y is not ex clusi ve to hos pita ls aff il - ia ted with healt h pr ofes sion al teachin g pr og rams . One we st- ions that If ho spital s can fin d other healt h care org anizat ern hos pita l men tion ed tha t they are part ici pating in a ha ve si mi la r nee ds or serve a sim ila r mix of pat ien ts, they y college. fo re ig n nur se progr am wit h a local communit As ex isting ca n com e to get her to creat e too ls or translate a me mb er of thei r hum an resour ces staf f sai d, “We ta ke al s to bet te r se rve th eir pat ient s. How ev er, in so me materi indivi dual s who are alr ea dy her e in this sta te wh o are ca ses, it may be diff icult to fin d a hos pital with similar lic ense d in ano the r co untr y, and the y go thr oug h a re tra in - need s, or ther e may be organ iz at iona l barr iers or res tric - ing to bec ome nur se s he re in th e Unit ed Sta te s. ” Progra ms tions to join tly de ve loping, ow ning , and sh aring materials. such as th ese hav e the pot ent ial to pr ov id e hos pit als with a Wo rki ng with oth er hos pit al s an d healt h care organiza - more di ve rs e wo rkf orce. As the CEO remark ed, “Ou r ho pe, ti ons is a gre at st ep forwa rd , but coll abor at ive opport uni - mo re bil ing ua l st af f memb ers .” ou r desi re, is to hir e many tie s can be ex pande d by invo lv ing ot her disciplines, gro up s, an d th e co mmunity in general. One is sue to keep in min d wit h re tr ai ni ng fore ign-born staf f is th at lite racy an d lan guage compe te ncy nee d to be Eng ag ingthe Commu ni ty asse ss ed in bo th the targ et la ngu ag e an d En gli sh. As one th e commu nity and maki ng use of exter nal Inv olving TA P me mbe r su gge st ed, th is pra ctic e cou ld be imp ro ved g dev elopin ls ta ke steps toward re sou rc es can he lp hospita if coupl ed with Engl is h as a Sec ond Lan gua ge clas ses fo r a more di ve rse wo rkfor ce, brid gin g cu lt ural ba rriers , and 42 the nurs es be in g recru ite d and retr aine d. be co min g a mor e ac tive par t of th e co mmu nit y. Co mmu nit y Partnerships to Cre ate a More Dive rs e Workf orce Collabor at ion wit h aca demic institut ions and tr ain ing pro gr ams has the power to pro vi de a comparable tha t are not af fi li ated with health op por tun it y for ho spitals s pro fes si on al te ach ing prog ra ms to esta bli sh pote nti al source 43 di verse workforce. fo r rec rui ting and tra ining a more In Ser vices in the Nation’ Ex pl or ing Cultu ra l and Linguistic s “We are worki ngwith[a] coun ty hospit al. , Hosp itals : A Repo rt of Findi ngs (H LC Rep or t of Findings) We want to be ab le tosha re our resources, have be en re co mmend 42 Prac tic es tha t engag e the community ed by bot h th e [especi all yfor] the[less commo n]languages “ use of the co mm unit y sh ould make — “H ospitals HLC Rep or t of Fin di ngs we see like Arabic, Croat ian, etc. ” re sou rc es ava ila ble thr oug h community ns, and pa rt - netw orks, col laboratio the inv olvement of community members nersh ip s, including from diverse –C&L services staf ffro m on formal board s and in hospit al pla nn in g cultu re s and la ngua ge groups awest ern hosp ital proc es se s” (R ecommendation 6-1) — as wel l as CLAS Standa rd 12 : ory, collabo ra tive at ions sh oul d develop “He al th care organiz par ticipat and utiliz e a var iet y of for mal an d info rmal part ners hi ps with communities t y and patient/consumer in vol vemen mecha ni sms to fa cilit at e communit 42 ” CLAS -rel at ed activities.” in des ig ning and implementing — Improvin g Care rec om men ds , “T he organ - 43 Impr ovi ng Com mun ication comm ns and other izat ion part ne rs wi th educa ti on al in stitutio uni ty organi za tions to ach ie ve work force goals an d enha nc e se rvi ce s, esp eci all y for com munica ti on -vu lnera ble po pu latio ns” (Con ten t Are a 4, 3.0). Performa nce Exp ec tation

43 CHA PT ER7: ishing and Ext ernal Collaborat ions Establ Internal ne rsh ips sho ul d not be ex cl usi ve to tra ditio na l healer s. As g hospi tals, local trai ning programs, Par tner sh ips amon ma ny pa tie nt s ma y ha ve cul tura l nee ds rel ated to re ligi ous and academi c insti tu tions are not limit ed to retraining be lie fs, hosp it als should deve lo p relati ons hips with local me dic al staf f. Ho spita ls should fore ign-born co nsi der s and re ligio us lead ers and institu tions to pro vid e re source that pro vide training out to any local programs rea ching gu idanc e for serv ing pat ient s wit h sp ecif ic need s. Th e in bilin gua l medical interp re ta tion, giv ing stud ents th e Nati onal Cen ter fo r Cult ural Comp ete nce’s Sharing a opp ortu nit y to compl ete an in ter nshi p or shado w pro - Le gacy of Car in g: Par tner ships Between Health Car e and Alter nate ly, if these types fessi onal heal thca re inte rpreters. Fa it h- Ba se d Org ani zat ion s ma y he lp orga ni zati ons exp lo re unity, of pr ogram s do not cu rr ent ly ex ist in the comm the po te nt ia l ben efi ts and ba rr ier s to devel opin g thes e ty pes toge ther pro gram s ca n work loca l colle ge s or training of col labo rati ons [34]. In addi tio n, hosp ital chapl ai ns often wi th hospit als to est ablish and pa rtne rsh ips to develop s, hel pin g hos pit als add ress pa tient s’ serv e as cult ura l broker tr ai n bili ngu al staff. Ob viously, deve lop ing new training ips ma y he lp fill ex is t- cul tur al ne eds . Whi le these partnersh pr ogr am s req uires both time and mo ney, which can be ing gaps in a ho spi tal ’s C& L-re late d se rvi ces, th ey ca n also have mad e of part nerships dif fi cult to fi nd, but a number pr es en t ma jor challe nge s. As one TA P me mb er men tio ne d, of their progr ams as we ll as some av ai la ble the structure thi s typ e of col lab or ati on, su ch as allow ing tra diti ona l cer - less ons lear ned, upo n whi ch hosp it al s can draw [31-33]. to be pe rforme d at the ho spi ta l, may require a em onies ch ang e in orga ni za tion al po lici es. Staf f tra ining on acc es s- Add iti onally, partne rs hips sh ould not be limi ted to co lleges ing the se se rv ice s and und ersta nd ing th eir ro le in th e pro - an d se co ndar y education hospital inst itut ion s. A western visi on of cu ltur al ly co mpete nt care may also be re quir ed. me nti on ed work ing wi th a loca l high sch ool to fin anc ia lly su ppor t high sch ool students who wa nt to go to coll ege for Becom in g an Acti ve Mem ber of the Comm unit y high sc hool students are heal th car e int erpr et ing. As many En gag in g the comm un ity als o invo lve s reach ing out to una ware of su ch op por tunities, it is imp or tant to re ach out com munit y me mbers and raisi ng awa re nes s of servic es ty an d estab lish rela tion ship s with loc al to the communi av ail abl e at th e hos pit al . The se ac tivitie s can in clu de such schools . How eve r, one TAP me mb er co mmente d, “Few st rat eg ies as adv ertis in g an d recruitm ent driv es; however, college s offer medi cal interpretati on as a ca reer, ” so this typ e com muni ty in te ra ction can co ns is t of acti vi ti es th at ar e of col lab orat ion may not always be an option. Therefore, cons id er ed mo re gras sro ots . On e sou th ern ho spital , for hos pita ls shou ld supplement thei r recru itment efforts with on go ing training sta ff. of existing bili ngual Us ing Com mun ity Lea ders to Bridge Cultu ra l he alth Barri ers To bet ter address cul tu ral or religious can develop relati onshi ps and collabo - beli ef s, ho spitals ra te with cult ur al or relig ious leader s in the community “We go to[high scho ol] job fai rs. Having a bi ling ua lrecrui terhel ps us alotwi th the se to meet patie nts’ needs . One wester n hospit al, for exam - eff orts[because ]the ycan influence theideas with a local e relat io nship pl e, discu ssed th eir cooperativ “ that so mestu den ts ma yha ve about gett ing ne man. Thr ough can Indian Ameri medici such par tner - intohea lthca re ornu rsing .We just had a guid - sh ips , tra dit io na l heal ers are on ha nd to provide sch ol arsh ipfored ucat ion aimed at vul nerabl e ance to patie nts and st aff on how to br idge gap s be tw een pop ul ations. By [rece ivi ng] that, [stu dent s] are n medi cin e. tr adi tio nal and Wester co mmi tt[ed ]to com[ ing ]back here and 43 work[i ng ]for us. ” The pract ice of developi ng partn ersh ip s with tra ditional –H uman reso urce sstaf ffrom heal er s is not lim ited to any parti cu lar cu ltur e. A sha man, awe stern ho spit al for exampl e, may help bridge cultural barr iers for Southeast the Asia n popu lat io ns, or a cura ndero ma y help address ” . However, need s of patients of Mexican descent these part -

44 CHA PTE R7: Estab lishing In tern al an d Ex tern al Col labor ations Conclu sions nic staff pers on to ex am pl e, shar ed th at they hired a Hispa Col labo rat io n, whe the r int erna l or ex terna l, may provi de wor k wit h lay health ed ucat ors in the His panic com mu - new av enues for hos pit als current ly und erta ki ng cult ura l y memb ers on ho w to use the nity to edu cat e com munit on competence ini tia tiv es. The re is no do ub t tha t collaborati hospital. A weste rn hosp ital menti on ed th at they have ne eds toplay arol ein all the pra ct ice sout lin ed inthi srepo rt. mad e form al effort s to talk to the co mmu nit y an d inform For ex ampl e, as hos pi ta ls de vel op C& L-rela ted org an iza - them abou t th e vario us se rv ices the hos pita l pr ovid es .This engag eand tio na lpol ic ies an dpr oc ed ur es ,lea dership should of av ailab le serv - type of outr ea ch ca n both raise aw areness in bri ng to get he r st akehol der s fr om mul tip le depar tments of est abli sh ing organizat ional a means ices and provide ord er tounder stan d the env ir on men t (s uppo rt s, const raint s, com mi tm en t and a level of tru st with in th e co mmu nity. are being carri ed out (se e etc.) in whi ch cur re nt proce dures Ch apter 4: Bui ldi ng a Fo unda ti on) . Colla bo rati on ma y als o As hospit als re ach out to their commu nities, th ey should have implicat ions for data col lect ion (se e Cha pter 5: als o con si der wa ys in whic h th ey can pr ovi de avenu es for 44 Co llect in g and Using Data to Impro ve Ser vic es) as hos pi tals To do th is, mo re coh esiv e. ma ki ng comm uni ty services may fi nd exte rn al organi zati ons tha t the y ca n wor k wi th to ho spi tals need to ide nti fy the va rious se rvic es that th eir coll ec tcom munity -lev el dat a. Addit ional ly, par tners hip swith the cont inu um of care. pa tie nt s may enco unt er thr oughout external orga niz atio ns ma y incr ea se access to re sour ce s tha t fo r exa mpl e, tra ins their in ter - On e nor th ea ste rn ho spital, sup pl em ent th e serv ic es pr ov ide d by the hosp ital (see and preter s to rais e awar eness of publ ic assist ance programs Chap ter 6: Acc om mo dating the Nee ds of Sp eci fic th e Sta te Chil dren’ s Health In sur an ce Program (SCHIP ) relation ships with cultu ra lbr o- Pop ul ati on s). Bu ildi ng active to he lp wi th hos pita l reimb ur sement. A CEO fro m a we st - ker s, tra di tiona lhe ale rs, cha pla ins, rel igi ou slea de rs, and other er n ho spi tal menti oned that their web site includes, “a lot ind ividual s ma y enha nc e and exte nd the ho spital’s exist ing of ot her prog ra ms that . . . pr ovide no n- heal th care sup - C& L se rvices. Wh ile col la bor ati ve effo rts co me with th eir hous - oth er typ es of temporary po rt —fo od co up ons [and] own chal le ng es, bui ld ing par tne rships tha t brin g to ge the r to pa tie nts whe n we need ing ass is tance tha t we can provide approp the cham pion s of cul tural ly and ling uis tically ria te ca n als o provi de resources to .” Alt erna tiv ely, ho spitals on care has th e potenti al to mo ve th e enti re fie ld for war d. The loc al adu lt learni ng programs fo r pat ie nt s with lim ited 45 se lf -asse ssm ent quest io ns provi de din cha pt er 8canhe lp hos- Th ese effort s may help hospit als skill s. he alth lit eracy pit als an d ot her he al th care org an izat ion s furth er exp lore ex isting ma te rials or crea te de velo p relat io nshi ps to revise opp or tuni ti es for int erna l or ext ern al col lab ora tio ns fo r ’ language new mat er ia ls that not only mee t patients needs 46 better mee ti ng the ne eds of di ve rse pa tien t pop ulat ions . but al so their he al th literac y need s. — Imp rov ing Care Im prov in g Co mmunication 44 re com me nds th at a he alth its com mu nity partne rs to faci litate com - care orga niza tion wo rk “with sizin g the ne eds of muni ca ti on outsi de of clini cal enc ou nters, empha “[Th edi rect or ofco mmu ni ty ou trea ch and comm uni cat ion-v ulnera ble po pu lation s.” On ce this partne rs hi p is int er pre terser vice s] ha stak en ast epwi th est abli sh ed wit h the co mm uni ty, the AM A’s Ethic al Fo rce Progr am sug - ge sts th at th ey “wo rk together to iden ti fy res ou rces , servi ces and ass ets the int er pr et ers—that theysh ou ld not just “ he al th about av ai lable with in th e com mu nity to ai d in com mun ic ating functionwi thi nthefour wa llsof the hospi tal; po pu lati ons ” erable an d hea lth care , espe ci ally fo r com mu nic atio n-vuln ns 3.1 and 3.2). (C onte nt Are a 3, Perform an ce Expe ctatio theysh ou ld act ual ly be outinthe com mun ity. ... Th is ho spi tal ,through itsint er pre terservi ce sand — Imp rov ing Care 45 su gge sts that “the or gani - Im prov in g Co mmunication za- wit h the po pu la tion s it se rves and co mm un ity organi za ti on [work] otherservi ce saswel l,ha struly go neoutand ti on s to help imp rov e he alth li terac y” (Con te nt Are a 5c, Pe rfo rman ce hasmined theint el lige nce that ’s out inthe Ex pect at ion 7.0). co mmun ity—the epi dem iology that ’s outin the Improv in g He al th Say?:” 46 Rec om me nd atio n III fr om “Wha t Did the Doctor co mm uni ty, the differe nt rel igious gro ups, and 44 sugge sts that he alth ca re or ganiz ation s Li te racy to Prot ec t Pati ent Safet y peopl elivi ng inthecom mu nity—an dsa id, “r ef er patie nts with low li te ra cy to adu lt le ar ning ce nt ers, and assist th em wit h enr ol lm en t pro cedu re s” and “e ncou ra ge pa rtne rs hips among ad ul t ‘How can webe streact tothat ?’” edu ca tor s, adu lt le ar ner s, an d hea lth pr of ess iona ls to develo p heal th- re late d cu rr ic ula in adu lt le ar ni ng progra ms, and conver sely . . . assist in –C EO from a s. ” and int er vention the de sign of patie nt-cen te re d hea lth ca re services north east ern hospi tal ”

45 to Meet the Tai lori ng In itia tives CH APTER 8: se Pop ula tio ns : Ne eds of Diver ent Too l A Se lf-A ss essm car e to ol is de sig ned to help hos pital s and other health al and Ling uistic Se rv ice s in the Nation’s Exp lo rin g Cultur or gan izat ion s disc us s an d exp lo re cu rrent C&L prac tice s in Hos pi tals : A Re por t of Finding Re por t of Find ings) s (HLC ord er to iden tif y po ten tial gaps and ar eas for im pro vem ent. show ed us a snapsh ot of 60 hosp it al s at differe nt points We beli ev e that the to ol pre sente d he re will sti mu la te th es e of the cultura l co mp eten ce conti nu um [3] . It also con - nt s of dis co ve ry and help staf f see their C&L serv - mome fi rmed th at hos pitals are challenge d to mee t the diverse ic es in the co nte xt of th e orga niz atio n as a wh ole. cult ur al an d langu ag e (C&L ) needs s they of the patient pract ice st and ard s for cul - serv e. Unt il evi denc e-based hos pi ta ls must cont inue tural com peten ce ar e developed, Ho wtoUse the Tool as bes t the y can. to mee t thes e dive rs e needs The go al of thi s to ol is to engage dive rse staf f membe rs dif fer ent se cto rs of th e orga ni zati on to co me from als are com ple x institutions, Hospit ea ch wi th uni que demo - toge th er and expl or e how th ey are cu rre ntly addr es sin g gr aphic , regiona l, hist oric, and financi ts. In order al contex pati ents ’ C&L nee ds. The benefi t of the tool is tha t it fo r C&L , th ey should pract ices to be effective be designed allo ws orga niz ati ons to th ink broa dly abou t ho w th ey to meet the needs of the organization and its pat ients. It is me et the ne eds of div er se pati ent popu lation s and con - and the sel f- asse ssment our hope tha t thi s report to ol con - sid er ho w proc es ses ma y be im pr oved upon to ref lect th e tai ne d in this ch apter will help ho sp ita ls and othe r healt h org aniz at ion ’s focus on ach ieving op timal pa tie nt ou t- cul tur all y and car e or ganiz ati on s tai lo r in itia tives to pr ovide co me s and redu ci ng he al th di spari ti es. lingu ist ic al ly appro pria te care. Organ Brin gin g Peo ple To get her fin d izati ons wil l likely dif fer ent way s to use th e se lf -a sse ss me nt to ol. So me The Se lf-As ses sment Too l or gan iza tion s may de ci de th at th ey wi sh to brin g Site visits for the Hos pitals , La nguag e, and Culture (H LC) toge th er a mul ti di sc ipli nar y gr oup or cre ate a high -le ve l to ge ther indi vid ual s at each hosp ita l for study br ought tas k for ce — as de sc ri bed in Ch apte r 4: Bui ldi ng a ho w care is bei ng prov ided to fo cu sed di scu ssio ns about Foun da tio n an d Ch apte r 7: Esta blishing Inte rna l and ally and lin gui st ical ly dive rse back - cultur pat ien ts from Ext erna l Coll ab or ati ons — to go throu gh th e self-as ses s- gr ou nd s. The inte rview ses sions we re ex pl orato ry, allow - men t que st ion s. Ano the r opt io n is to br ing to ge th er es in g parti cipa nts to share their ex pe rie nce s and ch alleng sm all er gro ups , dra wing from di ffere nt orga ni zati onal in me eting C&L ne ed s. We found tha t bringing staff le ve ls or di sci pl ine s. So me organ iz ati ons may decid e to how the ir organizatio to geth er to di alogue about n was appo in t ei ther a tea m or indi vi dua l to sp ea rh ead the at iv e no t onl y for the me et ing the se ne ed s wa s inform pr oces s. It ma y als o be use ful to have a gr oup fac ilitat or as well. Hosp it al staf f often stud y, but fo r pa rticipants he lp gui de di scus si ons an d give me mbe rs of th e gro up issue s from a new per - fo un d the mse lves viewi ng these an oppo rtuni ty to pro vi de inp ut. spe cti ve and gene rating new ideas for app roaching th ese situ at ions . can be a issues Bri ng in g peo pl e to ge th er to explo re C&L use ful way to sha re in fo rmat io n an d ensur e th at everyon e is can be The self- assess me nt tool at the end of this chapter In addi ti on , ind ivi du al inte rviews can on the same page. use d to gui de thes e types of discussion s and engag e mem - deta il s and en ric h the in for ma tio n collect ed. provide be rs of the organ izat ion in conversat ion s about the needs, 45 Orga niz at ions ma y consi de r using a comb inat ion of me th- an d goals for pro viding reso urces, the hig hes t qu ality care . Whi le some organ iza - od s to con duct the ir sel f-a sse ssment to every patie nt serv ed. The tool con sis ts of que stions, gen - tio ns ma y ch oos e to com plet e their as ses smen t in a one- day er all y open-ended, that are built arou nd the concep ts out - lin ed in ch ap ters 4 throu gh 7. The que stio ns are not sessi on , ot he rs ma y pr ef er a ser ies of sh ort er meet ings . ev alu ati ve, and the re are no right or wro ng ans wers. Th e

46 ives CHA PTE R8: Tailoring Initiat to Me et the Nee ds of Div erse Popula : tions nt Tool A Self- Assessme in te rp re tin g serv ic e, but di sc ove r that sta ff do not use it.To Me tho dsfor Cond ucti ng unde rs ta nd wh y this dis connect oc cu rs, the org ani zati on Self -As se ssme nt shou ld dete rm in e what fac to rs cont ribu te to the underu se •Fo cu sgroups •Smal l-gr oupintervi ews of the ser vice — pe rhaps staf f is unaw ar e that the servi ce •In-se rvi ces •Staff retre at is av aila bl e or is not comfor tabl e using it. •Lun ch meet ings •Tar geted intervie ws •Se minar ser ies We en co ur ag e or ga ni zat ion s to ha ve freq ue nt dial og ues abou t the pra ctic es th at ar e empl oy ed, in clu di ng how the Ch oosin g Pa rticip d is ants Rega rdles s of whi ch metho Are pr actice s are bein g eva lua ted. As kin g ques tion s such as to coll ect info rmation us ed , it will be imp ortant from a th e pr ac ti ces mee ting thei r in ten ded ai ms ? How eff ective are t disc ipli nes and lev els. of staf f repr esenting differen range the se curr ent prac ti ces ? How we ll are th ey fit tin g in wi th other A di ver se gr oup of stak ehold er s wi ll bri ng var ying expe - ho spit al pro ce ss es/ser vi ce s? Are there any ba rrie rs that sti ll need rien ces with C&L is sues to the table and provide a more to be ad dres sed ?What im pro vem en ts can be mad e? Ha ve the well-ro vie w of ho w th e or gani zat io n is currently unded sho uld be pr actic es re sult ed in an y un inte nde d cons eque nce s? mee ting the needs of div ers e pati ent s. a conti nuo us part of ongo ing organ izati onal imp rovem ent. Org ani zat ions ma y also co nsid er cond ucti ng a se lf -a ss ess- Pote ntia lPa rticip ants me nt in co nj unct io n with a ga p ana lysi s of curr ent pra c- •Intake sta ff •Ch aplain ti ce s, using re sou rc es su ch as the reco mm enda ti ons of the •La ngu ag eservices •Ch ief executi ve coo rdina tor office r and the Na tiona l Stan dar ds fo r HLC Re por t of Fin ding s •Me dica lsta ff •Ch ief medi cal of ficer Cultur ally an d Lin guis tic all y Appr opr iat e Ser vic es (C LAS) . •Nu rsin gsta ff •Ch ief nur sing officer •Pati en tad voca tes •Ch ief oper atin g pr acti ces , As hea lth care org aniz at ions pl an for new C&L •Pati en tsaf ety officer office r it is im po rt an t tha t the y und erst and the des ires and needs •Pati en ts an dfamilie s •Co mmunit ymemb ers of the ir st af f. Consi der at io n fo r th e pre fe re nc es of the st af f •Qu alit yimp rove men t •Di etar yser vices age the who uti lize the se ser vic es is on e way to encour of ficer •Di ve rsity off icer eff ec tive imp lem en tatio n of ne w prac tic es. In addi ti on, •Re crui ter •Financi al assist ance/ ne w se rvices sho uld be easy to us e and impo se mi nimal •Risk man ag eme nt bil lin gstaff [35] . del ay to ca re an d trea tment of ficer •Hu man resour ces •Socia lse rvices dir ector This rep or t do es no t pr ov ide a ste p- by -step gui de to •Staf f/cl inica led uca tor •Infor mat ion te nt . The roa d map to cu l- be co min g cult ur al ly compe tech nol ogy staf f n, and tur al com pete nce is uniq ue for ea ch or ganizatio th ere is no “one size fi ts all” so luti on. As show n by HL C study ho sp ital s, moti vat ors an d jo urn eys toward cu ltu ra l Bey on dSe lf- Assessme nt com pet en ce are di st in ct. It is our hop e th at th is re po rt Se lf -as ses sm en t sho ul d be a co nt inu ou s pr oc es s. On ce an ca n he lp orga nizati on s tai lo r the ir initi ati ve s to mee t the org ani zat io n ha s expl ored th e pra ct ices that it has in place uni que ne eds of th eir di ve rse patient populat ion s. ne eds, th ese pract ic es sh ou ld be mo nito red to mee t C&L and eval ua ted .The HLC st ud y fo un d that so me ho spita ls but dev elo ped pr act ices to me et sp eci fi c C& L needs, 46 they did not achiev e the des ire d resul ts. For so metimes ex am pl e, a hospit al may have a con tr act wit h a teleph one

47 CHA PT ER8: Tailo Initiatives to Mee t the Nee ds of Divers e Popul ations: ring ssment A Self -Asse Tool Self-A sses sment Too l We pro vid ethis sel f-a ssessme nt tool to help org anizations eva luate the way the ycurrently provide care and ser vice sto diverse pat ientpo pu latio ns. The too lis inten de dto add ress the main issues that emerged from the (HLC) study, an dthe qu es tio nsare des igned to promote dis - Ho spital s, La ngua ge, an dCulture cu ssion ar ou nd theneed to impro ve orexp and cur rent initi atives to meet patien ts’cultural and langua ge (C&L) needs .The ques tions are orga nized by four ke ythemes: Build ing aFoundat ion, Col lecting and Usi ng Dat ato Imp rove Servi ces, Accomm odat ing the Need sof Specif ic Populat ions, an dEstabl ishing Inter nal an dEx terna lCollabo rations. Bu ildin gaFo unda tio n al Competence e for Cultur ructur ve Infrast in g a Su pporti Develop of cultur ip curr entl y suppo 1. Ho w doe s our leadersh ally competen rt the pr ovision t care? an organiz ational reflect or othe r gui ding pri ncip les (e.g., vi sio n, values) state ment 2. In wh at way s do es our mission com mit me nt to prov id in g cul tur ally com pe tent care ? 3. How hav e we op er atio na liz ed ou r co mmitment to the provis ion of cu lt ur ally compet ent care int o organiza tion al an d reso urces ? ac ti ons, pr oc edu re s, ser vices, of the needs do our C& L servi ces ref le ct an und erstanding • How at ion? of the popul al, st af f) have we dedicated to C&L reso urces (e.g., • What ? act ivities financi t-pr ovider hav e bee n ident if ied to support o Wh ich interna activities l reso urces an d imp rove patien C&L com mu nica tio n? or pa y for C&L activitie s and improve o Wh ich externa l resource s have be en explored to provide patient- pro vid er commu nicat io n? 4. In wha t wa ys have we used the Nati onal St and ards for Culturally an d Lin gu is tical ly Appr opr iate Services 47 ete nce into organ iz ation al plann to incor por ate cu ltur al comp ing? (CL AS) or oth er gui danc e cul tur al ly and 5. Wh ich orga niz ati onal polici es and proce dure s, if any, set expectation s for staff for providing ri ate care? li ngu istic all y approp th e following: proce dure s that address • Do we have poli cies and/or o Rei nfo rcin g the im por tance of cul tura l sensitivi ty an d effective commu nica tio n in the provisio n of care o Sup porting th e use of prof es sio nal he alth care interpreter s o Di sc oura ging the use of fa mil y, min ors , or oth er untr ained individuals as interp rete rs teleph one, video) o Su ggesti ng wh ich types of la ngu age ser vic es are app rop riate for certain si tuati ons (e .g. , on-site, hout th e co ntinu um of care o Requ ir ing th e use of langu age se rv ice s throug tural conf licts that may arise or med iat ing any cr oss-cul o Re solving by them? ures and how to abide and proced policies traini ng ha ve staff recei ve d reg ar ding these • What monit is co mpli ance wi th th ese po li ci es and procedures ored? • How Inte gra ti ng Cu lt ure and Language in to Or gani zat ional Systems rt st aff diversity? goals suppo 6. Wh ich of our organizational • What are our stra tegi es for st aff recr uit ment? 47 are our stra tegi es for st aff ret ent ion? • What Language As sistance Self- Assessment and Planning Tool for Recipients of Feder al Financia 47 Other gui danc e may inc lud e the Unit ed States Department of Justice’s l tment of Health and Hum an Servic es’ Patient-Centered Guide Assis tance Language Access Ser vices in Healthcare [36 ], Unite d Stat es Depar to Implementing and Organiza tions [37 ], and the Amer ican Co ll ege of Healthcare Ex ecut ive, Am erica n Ho spital Associati on, Institute for Div er si ty in Health Management, Strat egi es for Leadershi Nat ional Cente Pr oficiency A Diver sity and Cultural It Serves, the Co mmunity p: Doe sYour Ho spital Reflect r fo r Hea lth care Leader sh ip’s [38]. Assess me nt Too l for Lea de rs

48 CHA PTE R8: Tailoring Initiat ives to Me et the Nee ds of Div erse Popula tions : A Self- Assessme nt Tool 7. Wh ich members g C&L initiatives? of ou r organi zat ion are responsible for coo rdinatin ? initiatives • In what wa ys do es le ade rsh ip sup port th ose in ch arge of C&L ives ? C&L initiat ted staff posi ti on for coor dinating 8. Is th ere a dedica o Wha t are th e po si ti on’s sp eci fic res po nsibil ities? o Do es th is po siti on re po rt to an exe cuti ve in the organization? ive s? • Is th er e a high-le vel task for ce that coo rd in ates C&L initiat ser ves on th e task force? o Who to the org aniz ation ? o Ho w ma ny mem ber s are inte rnal or external represe o Ar e there a rang e of st af f le vels an d di sciplines nt ed? o Ho w often do es the task forc e mee t? to en sure the y addr es s the di verse needs o How does the task for ce revie w polic ies and proc edures of patients and st aff? o Ho w does the task for ce sup port eff ort s for ongoing cultu ral competenc e tr ainin g for staff at all le vels? ? dations o Wha t is the pro cess fo r imp le ment ing task force recommen services? 9. Wh at ty pes of financial sys tem s are in place to remove barriers to usin g C&L • How do we bud get fund s for the provi sion of cultural ly appr opriate ser vic es ? o Ho w do we budge t fund s for the provis ion of language ser vices ? interpreter o Can we ma na ge co st s by canc ellin g/re sch ed uling appo in tmen ts wh en pat ie nts canc el /res chedule ap point me nt s? ete nce in to Patient In te grat ing Cu lt ur al Comp Care 10. Are we eff ectiv ely using staf f acro ss di sciplines to provide appr opr ia te care? ly an d lingu istically cultural 11. Wh at forma l systems patie nts’ C& L needs ? do we have for identifying needs • Have we deter mi ne d the firs t poi nts of contact at wh ich C&L are best identified? needs ? with language • How do sta ff han dle pho ne call s fro m patients ts with la ngua ge ne eds (e.g., auto ma te d sys te m, operat or) • Ho w do es the phon e sys tem hand le ca lls from patien the cont inuum th roughout fol lo ws th e patient C&L needs • How do we ensu re that inf or mati on regarding of ca re? serv ices? lan guage 12. Wh at to ols are provi ded to st aff to de termi ne th e appropriate needs • Wha t re so urce s are av ailab le to id entif y la nguage ing services )? (e. g., “I Speak ” cards, tel eph one interpret • Wh at tr ai ning ha ve staf f rece ive d to un derstand and use th e res our ces avail able to identify lang uage needs? meet patients’ needs? 13. Wh at to ols an d resou rces are avail able to staff to help them cu ltural of the se too ls? • How are sta ff mad e aware of the pat ient • Wh at ty pe of tra in in g have st aff re ce ived to help th em meet the uniq ue cu ltu ral needs po pula ti on? 14. Ho w are sta ff made of C&L ser vices? aware of the avail ability care level to en su re vis ibil ity? ser vi ce s in cor po rat ed at th e patient • Ar e inter preter iate use of C&L the appropr • Wha t type of tr ain ing have staff rece ive d regarding services? 15. Wh at ty pe of tr ai ning have staf f re cei ved regar ding how to acces s C&L ser vices? • Are sta ff aware of th e reg ulat ory re quireme nts , man date s, an d nat io nal st and ar ds regar di ng the provis io n of 48 lan gu age ser vi ce s? ser vic es du rin g hou rs, after -hours, • Wh at interna l ma te rial s are avai labl e on how to access and for C&L cer ta in dep ar tmen ts (e.g., the emer ge ncy room)? contr act in ter preters or vid eo , telephone • How are C& L ser vices acce ssed (e.g ., on- sit e interpreters, al serv ices, dietar y serv ic es, etc .)? chapl ain, re li gi ous and spiritu la ng ua ge ser vices,

49 CHA PT ER8: Tailo Initiatives to Mee t the Nee ds of Divers e Popul ations: ring ssment Tool A Self -Asse services? d for th ose pr ovid ing language 16. Wh at type of trai ning is require • If usi ng sta ff to interpret: staf f are pr of icient in English and the target o Is th ere a policy releva nt that ensures langu age, incl uding med ical ter mino log y? staf f und erstand o Is th ere a policy Healt h Insurance Portabil ity that ensures th e rol e of th e interpreter, Act (HIPAA ) and co nfidentiality issues, and int er preter code s of ethics and and Acco un ta bility st and ard s of pr acti ce? o Are th er e requi reme nts for ongo ing tes ting and trai ning? interpreters? o Have guid elin es been deve lop ed for dual-role for lang ua ge se rv ices: • If usi ng an ou ts ide vendor th at agency interpreter s have to meet? o Are th er e st anda rd s for traini ng and co mpetency that outsi de ve ndors comply al po licies an d procedures related to o Does th e hos pi tal ensure with hospit HIPAA, con fiden tiality, ethi cs , and standards su ch issu es as la ngua ge prof ici ency, th e role of interpreters, of pr actice? do we ens ure that co ntr act inte rpreters are meet ing those stan dar ds ? o How ials (e.g., informed 17. Wh at type s of wr itten mater medication inform atio n, discharge instructions) does consent, or have trans late d into patients’ primary languag es? ou r or ganiz ation create • Are pro fess io na l translators us ed to transl ate materials? ials? • Is there a for mal quality revi ew proce ss for these mater • Is there a ce ntra l repository ize dupl ication and control the quality of fo r transl ate d documents to minim the docum ents? are heal th li teracy by written mater ial s? • How and cul tur al issue s addressed video or audio or low healt h liter acy skills (e.g., • Are oth er op tion s av ai lable for pat ie nts wit h low literacy ins tr uctio ns) ? is th e proc es s for tr ack ing pri nt mat erials ? for revis ions and updates • What Co llectin gan dUsing Data to Imp rove Services Ass ess ing the Ne ed for C&L Service s 18. Ho w have we assess ed the C&L nee ds of the community? type of communi ty- leve l demog raphic data do we collect (e.g., age, gen der, race/ethnicity, primar y • What sp ok en and/ or wri tte n language, so ci oeco nomic status, religion, health liter ac y lev el , etc.)? o How of ten are the se data coll ect ed ? o Are th ese da ta self -rep ort ed? o Do staff in all dep artm ents/ care uni ts have access data? are these • What me tho ds do we us e to coll ect data fro m the community? o Have we cond ucted with comm un it y leaders, pat ients, and ind iv id ual inte rv iews and /or focus groups local bus iness es ? o Ar e there other data reg arding comm un ity dem ographics that we can ac cess ? 19 . Ho w have we assessed the C&L nee ds of our patients? • What type of pati ent-level demo grap hic dat a do we collect (e.g., age, gen der, rac e/ ethnicity, primary 49 sp ok en and/ or wri tte n language, re li gi on, se xual orientation, disabilities , cu ltu ral needs, dietary needs, he alth liter acy lev el, etc.) ? • How do we ens ure th e accu racy of the dat a? o Do we co llect data di rect ly fr om our pati en ts?

50 CHA PTE R8: Tailoring Initiat ives to Me et the Nee ds of Div erse Popula tions : A Self- Assessme nt Tool and com - o Ar e staf f tr ai ned on the be st way to obtain data in a mann er th at is res pec tf ul to th e patient fo rta bl e fo r the sta ff? Trus t (HR ET) Toolkit ch an d Edu cational o Has the or ga nizat ion ut il iz ed too ls such as the Health Resear fo r co llecti ng da ta on race , eth nici ty, and primar to aid th eir data coll ecti on ef fort s? y lan guage • Wh at are our po lici es and /or pro cedu res th at addr ess the syst ematic coll ec tion of data? 20. Ho w are th es e data use d to cre ate C& L initiat ives? Mon it or ing C&L Service Utiliz ation 21. Ho w are cultur al is sues inco rp orate d into patient care? • How often do cultur al issue s have an impact on patient care? beliefs rituals, and , folk rem edies , traditions, • Do staff co ns ider re li gi ous and sp ir it ual beliefs , cultural alt er native ne whe n pr ov id ing care ? medici to related beliefs g cultu ral an d religious • Wha t sk ill s do st aff ha ve to explo re pat ien ts’ pers pec tives includin hea lth , ill ne ss, an d treat men t? arise? • Do staff document situat ions in wh ich cultural issues o Do chap lai ns recor d encount er s wi th pat ients? o Ar e di etar y co nsi de rat ions reg ardi ng culture and/or relig ion rec or ded? 22. Ho w are la ngua ge is sues inco rp or ate d into pat ient care? • Is th ere fo rma l do cument at ion of int er preter encount ers? record )? is the enco unte r docume interpre ter log, patient’ nte d (e.g., s medical o Where vi de o)? o Is th e type of int erp re te r docu ment ed (e.g ., on-s ite, te lephone, ing int er preter en counters? a poli cy for do cument o Is there inte rpreter enting ted on the imp or tance o Ar e staf f educa en cou nters ? of docum • Ar e enc ounter s docume nte d whe n an interpreter has been off ered bu t has been refused by a pat ient? ser vices? ing the ref usal of interpreter a poli cy for do cument o Is there eter services? the ref us al of interpr enting of docum ted on the imp or tance o Ar e staf f educa ncy, cos t, and quality? • Ar e the diffe re nt for ms of in terpr eters (e. g., on-site , telephone, video ) ev alu ate d for efficie an d com pa red to the C& L need s ident ified 23. Ho w are da ta regardi ng th e use of C&L ser vices reviewed th ro ug h demog ra ph ic dat a coll ect io n? Servic es to Imp rove C&L Data Using provid we currently e? 24. Wh at is the bas eli ne for the C& L se rvices • Can we use th is bas eli ne to co mp ar e ou r progress ser vic es ? as we impr ove C&L ser vices? 25. Ho w do we measure the quali ty of our C&L ts an d st aff? from patien are in pl ace to col lec t fe edback • Wh at sy stems with to patients infor mation • Ar e we aski ng the right que st ions to obtain regar ding th e car e we provide C&L needs ? fr om pati ents with language needs ? • How do we obta in fee dback o Do pat ient sa ti sfac tion surv ey s in cl ud e questions about C&L ser vi ces? o Is there a mech anis m in place to tr anslate written surv ey s an d patient res pons es? 50 pa tien t sat is faction data? o Ar e fo cus gro ups and pat ie nt inte rv ie ws used to obtain • Ar e our pa tients to them? resou rces , and tools provided services, unication sat isf ie d wi th the comm data use d to impr ove C& L services? • How are these

51 CHA PT ER8: Tailo Initiatives to Mee t the Nee ds of Divers e Popul ations: ring ssment Tool A Self -Asse care and im prove di sp ar itie s in health C&L 26. Ho w are data used to identify ser vic es? in dicators, adver se event s, etc., str at ified by and quality es, perf ormance • Are data reg ard ing outcom de mo gr aph ic va ria ble s? • Whic h demog ra phi c vari able s are use d to stratif y data? on syste m in place to link demograph • Is there to facilitate analysis ? an informati ic data to oth er inf ormation ser vices provided • Are thes e resu lts used to imp rov e th e C&L for dive rse populations? Ac commo dati ng the Need sofSpe cif ic Populations ng Staff Aware Pr omoti Train ing , Dialogue, and Suppor t ness through th e importance of effective communic atio n in the provis ion of car e? 27. Ho w doe s staf f traini ng address address th e role s th at languag e, literacy, and culture play? • Do es tr aining and ongoing training? • Are thes e iss ues address ed du ri ng ori ent ation available to meet the C& L need s of patients? • Are staff provided re sources traini ng on ho w to access o Are th ey tra ined to access one, or video in terpreter s? on-si te inter preters, teleph type of tr ai nin g have st af f rece iv ed on how to work with interpr ete rs? • What 28. Ho w are staf f educated on th e uni que C&L needs served ? of th e patients cultur et ence tr aining? • Do staff receive al comp o Wh en doe s tra ini ng occur ? o Is th e tr ai ning requi re d or op tio nal? of ten is tr ai ni ng prov ided (e.g., o How orientation, annually to all staf f)? during o Wh at issue s are add ress ed in th e tr ai ning ? o Wh o provid es the tr ai ning? ity? 29. Wh at educa tio nal materi als an d tool s are st aff provided regard ing the C&L iss ues of the service commun • Are ther e any on li ne ap pli cat io ns or intranet resources that pro vi de cros s- cu ltu ral inf ormation ? to dialo gu e about es en co untered? unity the cultu res an d languag • Do sta ff hav e an opport rat e compe te ncy regard ing the use of C&L resour ces and tools? • Are staff required to demonst e existing language services ? or bet ter facilitat 30. Ho w ca n tech no logy enhance d to proper ly us e tele phone or vid eo medic al interpretin g ser vices ? • Are staff traine t prese nt in patient (e.g., spea kerphon e, du al hands et telephones, rooms • Is the appro pri ate equi pmen vid eo equ ipm ent)? communication boards made av ail able to supplement • Are speec h outp ut devi ces and /or bi li ngual la nguag e ser vices? Creat ing an Environment that Mee ts Speci fic Patient Needs 31. Wh at as pects of th e phy si cal en vi ron ment to det ermine wh ether they meet specific have been evaluated pa tient nee ds ? • Is si gn ag e reada ble, in ap pr op ri ate language s, and available th rough out th e organization? • Is it eas y fo r pa tients to identi fy an d access th e organization’s entr y points ? y? 32. Wh at ch anges to the physical environment th at support patien t diversit hav e we made • Are ther e ro oms available for sp eci al patient needs such as pray er, famil y con fer ences, and individual 51 con sulta tions ? translated in to ou r most dominant languages • Do we have pati ent ri ghts and res po nsibil it ies documents and po sted in clear vie w of al l major ent ry points ? • Have we co nsidered way s to acco mmodat e patient s wit h large families ?

52 CHA PTE R8: Tailoring Initiat ives to Me et the Nee ds of Div erse Popula tions : A Self- Assessme nt Tool ? 33. Ho w hav e we adapted our pati ent care ser vices to incorporat e cul tural beliefs date patien t needs ? • Is th ere a need to modi fy vi si tati on hours to accommo res to ac com mod at e cu ltu ral consideratio ns? an d procedu • How can we ad just our policies ou r comm itment • Do ou r die tary men us reflect to div ers ity and cu lt ur all y com peten t care? Hel pi ng Pat ient s Manage The ir Car e 34. Wh at prog ra ms do we have that help patient th e heal th care sys tem? s underst and and navigate • Do we ha ve ed ucat ional re so urc es th at ex plain the health care sy stem ? • Wh at mech ani sm is in pl ace for pat ie nts to ask quest ions about th e heal th car e system? • Ar e staf f ava ila ble to assi st pati ents wi th insurance, pay me nt , and logistic al is sues ? ts make s info rmed decision 35. Wh at ty pes of patient ed ucati on and training do we provide th at hel p patien and acti vely pa rtic ipa te in the ir care ? into th e most comm on pat ie nt g labels and warnin tr anslate • Doe s our in -ho use phar macy prescription la ng ua ges? cul tural • Do di sch arg e inst ruc tio ns take int o ac cou nt su ch fac tors as a pat ien t’ s lang uage, health literacy, suppo rt, et c.? beli efs , acc ess, chil d care, family edu cation? • How can techn olo gy be use d as a tool to prov ide patient materials o Ar e electro nica lly tr ansl at ed pat ie nt education ass es sed for ac cu rac y? • Ar e pa tients giv en an op portuni ty to ask questions regarding th eir ins tru ctions ? (e.g., ask ed qu estions, teach-back pr ocess es)? • Ho w ar e pa tie nts as sess ed for co mpr ehension of their ins tr uctions ions of Lar ge Populat Needs Specific that Meet Est ab lis hi ng Ce ntra liz ed Programs ions ? of our lar ger populat to addres d pro gr ams have been developed lly centere 36. Wh at cultura s th e needs cultura lly foc us ed? • Ar e th ere any curre nt pr ogr ams th at could be more and spirit ual belief s? 37. Wh at prog ra ms have be en bui lt aro und re ligious ? religions of multiple • Is our cha pla incy serv ice di ve rse and inclusive Es tab lis hi ng Interna landExternal Collaborations al within Wor ki ng Tog ether th e Hospit coo rdinated within our organ izat ion? 38. How are ac tivitie s and init iat ives rela ted to cultur ally com pet en t car e being ization • How are we invo lvi ng dif fere nt st akeh olders from across to coll abor ate in C&L th e organ efforts? o Co mmittees ma y consi st of : med ic al staff , past or al car e, in terp reti ng servi ces, o Staf f (cli nica l and ad mi ni st rative le ade rsh ip, nursing, st aff, cult ur al soci al wor k, huma n reso urce s, pati ent safety /risk manag ement , qual ity impro vement ty out reach /mar ke ti ng, etc.) br oker s, co mmuni o Patients o Com munity lea de rs o Reli gi ous lea der s g pe rs pect ives with in the organ izatio n (inc lu din g va rious departments , • Do st ak ehol de rs re presen t varyin posi tion s, profe ssion al levels) ? 52 • Do stakeho lder s rep re sent the vary ing perspectives within th e com mu nity (e.g., cul tur es, rel igions)? • Wh at activi ties are stak eh old er s ov er se eing? o Ho w are these C&L ac ti vi ti es bei ng ce ntrally coordinated? • How are sta keho ld er s add ressi ng pati ent and/or issues? to C&L related staff concerns

53 CHA PT ER8: Tailo Initiatives to Mee t the Nee ds of Divers e Popul ations: ring ssment Tool A Self -Asse Bri dg es wi th Ot her Hospit als Building 39. Wh at existi ng resources an d national as sociations? can we share with oth er org aniz at ions or local, state, care th at we could shar e with othe r competent • Are ther e bes t pr acti ces rel at ed to imp lem enting culturally or ganiz ation s? d fr om implementin learne ca re th at would be useful to share with • Are ther e any lessons g cultu rally co mpetent oth er or gan iz ation s? • What of inf or mati on woul d we like to learn from other organizations ? types reso urces are available that oth er organizatio ns can share with us? • What • What or gani za tio ns or ty pe s of or ganiz ations or resource s with? do we want to sh are infor mation do we want to de velop in collaboration 40. Wh at reso urc es or materials with oth er organizations? (e.g., a multi-hospital with oth er or ganiz ations • Are ther e specif ic typ es of res our ce s we want to develop rk , educat ional re sour ces, or trans lations of vital docu men ts suc h as consent for ms, inte rp reter netwo for ms, patie nt rig hts inf or mati on, intake forms, com plaint etc.) • Whic h lang ua ges sh ou ld we targe t? or oth er he al th care organiz sh ould we collaborate with ? • Whic h hos pitals ations En gagi ng the Community 41. Ho w many community ntati ves are involved in our C& L-related comm ittees? represe be helpf ul ? • On wh at oth er co mmi ttees wo uld havi ng community rep resentatives • Do the communi ty rep res ent ati ves cur re ntl y involv tives of the diver se needs of ed provide perspec the popu latio ns we se rv e? have we iden ti fied to pa rt ner with educati and tr ain a diverse 42. Wh at op po rtu nities onal ins titu tions to recruit wo rkfo rce? are avai labl e for tr aining current staff ? • What opp ortu nities types of recruitment oppo rtuni tie s are available in the surroundin g com mun ity? • What incentives bilingu al staf f? are we prov id in g to re cruit and train a diverse, • What ities for de vel op ing a fut ure diverse wo rkfor ce? • Are ther e opportun exi st that co uld hel p us better meet C&L needs ? 43. Wh ich co mmu nity res ources communi zati ons or ne two rks can we collaborate ty organi • What wit h to hel p br idge cultu ral barr ie rs? • What relig io us leaders relationships with to meet patient needs ? or chap lai ns have we dev eloped wi thin the community • Are ther e tr adi ti onal healers to wh om we can reac h ou t? • How hav e we tra ined staff to be aware of and access th ese external res our ces ? 44. Ho w have we re ac hed out to th e commun it y and/or facilitated access to both in ternal and exter nal services? • Are pat ien ts awa re of th e com mun ity programs tha t rel ate to patients’ continuum of care? or serv ices av ailable • Are ther e pu bli c ass istance prog rams that we could help pat ients becom e more awar e of as part of their overa ll care? with to help with is sues of health liter acy? • What adul t lear ning program s could we partner 53

54 Appendix A: Endn ot es 1. Sm edl ey BD, Stit h AY, Nelso n AR. Conf ronti ng Ra ci al and Ethn ic Di sparit ies in Hea lth Ca re. Unequal Treatment: Was hin gton , DC: Na tion al Acad emy Pre ss; 2002. Ho spital Lan gua ge Services 2. Hasna in-Wy nia R, Yone k J, Pi erce D, Kang for Pa tien ts with R, Greis ing CH. al Trus t Limite d Eng li sh Pr ofi cien cy: Re sult s from a Na tional Surve y. Ch ic ago, IL: Heal th Res ear ch & Education and th e Na tio na l Healt h Law Pr ogr am; 2006. Hos pi ta ls , Language, Expl oring Cultural A Sna psho t of the Nation and and Culture: 3. Wi ls on -St ron ks A, Galv ez, E. Oakbr oo k Terr ac e: Th e Joint Commission; Lingu ist ic Serv ices in the Na ti on’ s Hosp it als A Re po rt of Findings. 2007. invol ve ment 4. Br as he rs DH , Ste ph en M, Ne idi g JL. The Patient Self-A dvocacy Scal e: Meas uring patient in 121. 1999:97- He al th Com mu n. health ca re deci si on- maki ng int er acti ons. 5. Mare lich WD, Mur phy, DA . Ef fect s of empowerment among HI V-po sitive women on the patient-prov id er rela tio nsh ip. AIDS CARE . 2003;15:475-481. L, Har dt EJ. Err ors in medical 6. Flo res G, La ws MB, Mayo SJ, Zuck erman B, Abreu M, Medina in ter pre tation Ped ia tr ic s. ence s in pediatr l clini cal co nsequ and th eir po tentia Jan 2003;111(1):6-14. ic enc oun ters . 7. Di vi C, Koss RG, Sch malt z SP, Lo eb JM . Langua : a pilot stu dy. and adver se even ts in US hospitals ge proficiency Int J Qual Hea lt h Care. Apr 2007 ;19( 2) :60-67. 8. The Jo int Commission. Roo t Ca use s of Sent inel Events 20 06 . Avai la bl e at : ht tp :/ /www.j ointcommi ssion. org/NR/ jpg. Acc essed Febr ua ry 19, 20 08 . 0/ root _c ause_se. rd only re s/ FA4 6564 6-5 F5 F-45 43-AC8 F-E 8AF 6571 E372/ 9. Wo ol f SH, Kuz el AJ , Do vey SM, Phi llips RL Jr. A string of mistakes : the im port ance of cascade analysis in 326. descr ibing , coun ti ng, an d pre ve nt ing medi cal err or s. Ann Fa m Me d. Jul- Aug 2004;2(4):317- lang uage barr ier s in heal th care: costs and benefits 10. Jaco bs EA, Shep ar d DS , Suay a JA, St one EL . Ov ercoming ser vices . of inter preter -869. Am J Pub lic He al th . May 2004;94(5):866 s wit h care fo r patient 11. Karl in er LS , Jac obs EA , Chen AH, Mu tha S. Do pro fessio nal int er pr eter s im pro ve clinical A sys tema tic rev iew of th e literat ur e. He alt h Se rv Re s. 42(2) :727-754. Apr 2007; li mi ted Engl ish proficiency? competent culturally 12. Br ac h C, Fra ser I. Re duci ng dis par it ies th rough health care: an anal ysis of the business r 2002;10(4):15-28. ca se. Qual Manag Heal th Care . Summe in heal th care: The Joint Commission di ffe rence s as a barrier 13. Sch yve PM. Language to quality and safety per - Nov ;22 Su ppl 2:360-1. Med. J Ge n Intern spec tive. 2007 . Impr ovi ng Com municatio n — Improving Care: 14. Am er ican Med ica l As soci ati on, The Ethical Force Program Ho w He alth Car e Org anizat ions can Ensu re Ef fe ct ive , Pati en t-Ce nt er ed Com mun ic at io n with Pe ople fro m Diverse Chi cag o, IL : Eth ical For ce Progr am, Americ al As soc iation ; 2006. Po pulations. an Medic 54 Health. Off ice of Minority 15. United Sta tes De part me nt of Heal th an d Human Na ti onal Standards Services, fo r Cultu rally and Ling uistical ly Appropria te Servi ces in Heal th Car e. Wash ing ton , DC: HHS; 2001. Pa ti ent Safety . Wh at Did the Doctor 16. Th e Jo in t Co mmi ssi on. Say ? Imp rovin g He alt h Lit erac y to Protect Oa kbroo k Ter ra ce, IL : The Joi nt Commi ssion; 2007.

55 s App end ix A: En dnote of Health 17. Ad apte d fr om Cross of Min orit y and US De partment and Hum an Services, et al., 1998 Office m. Ac ces sed December .gov /about 19, 2006. Ava ila ble at : www.ahrq He alth, 2000. /cods/cultcompdef.ht 18. Na ti onal Co un cil on Interpret ing in He al th Care. The Term inology of Hea lt h Care Interpreting: A Gl oss ary of Te rms. in Health Wash ing ton, DC: Nati ona l Co uncil Car e; 2001 . Avail abl e at: on Int erpr eting etin g.pdf . Ac cessed areInterpr osjun to s.o rg /p df _f iles /The Terminolo ww w.hablam gy ofHealthC on Fe bruar y 19, 2008. SC, Brac h C. JA , Kr ipal ani S, McMorris 19. Jaco bs on KL, Gazma rarian KJ, Blake Is Our Ph arma cy Mee ting cont rac t under (Prepared Tool User’ s Guid e. Pat ien ts’ Nee ds ? A Phar macy He alth Lite racy Assessment Rockv No. 290-00- Agenc y for Healthc ar e 0011 T07) AHRQ Publ icat io n No. 07-0051. ille, MD: Researc h and Qua lity ; Octo ber 2007. Ser vices, 20. United Gu idanc e to Federal State s Department of Heal th and Human Office for Civil Rights. n Affectin g Against Financ ia l Assi stan ce Re cipie nt s Re gar din g Titl e VI Prohibition Nat io nal Origin Discriminatio Was hing ton, DC: HHS;2003:68 Limited Eng lish Pro ficie nt Pers ons. Fed . Reg. At 47311-47323. d, CA: California Strai ght Talk: Model Oaklan Hospit al Policies 21. Par as M. and Proc ed ures on Lan guage Ac ces s. He alth Care Sa fety Ne t In sti tute ; 2005. Cult ural an d Lin gui st ic Compe te nce Po li cy Asse ssment. 22. Geor getow n Na tional Cen ter for Cult ural Competence. a.inf o/. Acce ssed Februar Ava ilabl e at: www.clcp y 21, 2008. Co nducting Co nce rns Sur ve ys. 23. Unive rsi ty of Ka nsas, Wor k Group for Community ent. Healt h and Developm m. Accessed ar y 19, 2008. u/e n/ta bl eco nte nt s/ sect ion_1045.ht Ava ilabl e at: ctb.ku.ed Febru 24. Exe cu ti ve Off ice of the Presi de nt, Of fice of Management and Bu dget (OM B), Office of In form ation an d of Federal Data on Race and Ethnicit y, Regu lator y Af fair s. Rev isio ns to the Standards for th e Classif ication iv e Of fice of the Presiden ngt on, DC: Execut Available at: Fed eral Regi ster No tice. Washi t; October 30, 1997. rds.h tml . Accessed ho us e.go v/omb/ ww w.white Februar fed reg/ 1997standa y 19, 2008. C, Prince A, Hed ges Greising J. He alth Re se arch and R, Pi er ce D, Haque Wynia 25. Hasnain- V, Reiter Chi cago, IL: Health Research & Edu cation al Trust; 2007. Available Educati on al Tr us t Di spari tie s Toolki t. 19, 2008. at : www.h re tdis pa ri ties.o rg . Accesse d Fe bruary Ser vices, Resour ces and Services Administration. 26. United Health of Heal th and Human State s Department y, Cultural Com pete ncy, and Limited English Health Uni fied He alth Co mmu nicat ion 101: Addressing Literac hr sa.gov /he al thliteracy /training .htm. Acces sed on February 22, 2008. Pr of ici en cy. Ava ila ble at: www. Services, Office Health. A Ph ysic ian ’s Pr ac tical Guide of Hea lt h and Human 27 . Uni ted Sta tes Depa rtment of Minority . Accessed Ava ila ble at: cccm.thinkculturalhealth.org/ t Care . to Cul tu ral ly Competen on Fe br uary 22, 20 08 . 28. Kel ly N. Teleph one interp retin g in healt h care set ting s: some commonly as ked questions. The ATA 55 anet.org/ch ronicle/ feature_artic le_jun e2007.php. Ch ro ni cle . Ju ne 2007. Avai labl e at : www.at Acc ess ed on Februa ry 19, 2008. to cancer access fol low- up among the an d cl inical screening 29. Free ma n HP, Muth BJ, Kern er JF. Expanding 1995;3:19-30. Can ce r Pr act. med ically und er serve d.

56 Appe nd ix A: Endno tes . On col Issues . 2004 Sept/Oc t;19:44-46. 30. Freem program an HP. A model pati ent navi gation os Juntos . Center g Dev elo ping a Medical al Nebr aska – Area Heal th Education 31. Centr , Inc., Hablam In te rpretin ablam 2005. s Juntos; Fre sno, CA: Hablamo Tr ain in g Pr og ram. osjuntos.or g/ Avail ab le at: www.h . Ac ces sed Februar NAHEC.pdf de_po rta l/ pd f/ 13Tr aini ng _P rogr am-C res ou rce_gui y 19, 2008. Fresno, CA: 32. Hablamos Junto s. Educat ional Partn erships for Interpr eter Traini ng: An Hab lamos Junto s Ini tiative . pdf/ Hablam os Junto s; 2005. Avai lable at : www.hablamosjuntos.org/res our ce_gu ide_portal/ 12T raini ng_Pro February df . Accessed gr am_ Pr of ile _091405.p 19, 2008. Certific ate 33. Na tio nal Lin guis tic & Cu ltur al Pro gr ams (NLCP), Kaiser Perman ente. Healt h Car e Interpreter Febru Prog ram [w ebpa ge] . Avai lable at: www .k ph ci.org/. Accessed ary 19, 2008. n He alth Care an d 34. Na tio nal Center Sh aring a Legacy of Car in g: Part ne rs hips Betwee for Cul tur al Co mpe tence. Univers ity Ch ild Developm Washi ion s. Fait h- Base d Org anizat ent Cen ter; 2001. ngto n, DC: Georgetown langu age ser vices: th e quali ty of hospital 35. Reg ens tei n M. Meas ur ing and imp roving ins ight from the Speaking 2):356-9. To gethe r co lla bo ra tive . J Gen Int ern Med. 2007; 22(Suppl Section, Civil Ri ghts Division. 36. United Sta tes Dep artment of Justi ce , Coor dinat ion and Review Lan guage ton , DC: Washing l Financial Assist ance. ts of Federa As sis tanc e Se lf- Asse ssme nt and Pl ann in g Tool for Recipien DOJ. m. Accessed Febru ar y 19, 2008. Ava ila ble at: ww w.lep .gov /se lf asses stool.ht A Patient-Ce nte red Gu ide 37. Uni te d Sta te s Depa rtment of Healt h and Hum an Servic es , Office of Min or ity Health. Was hin gt on , DC: HHS; zatio ns . Organi to Implem entin g Lan gu age Acces s Servi ces in Healthcare 2005. 1- 253. te for Diver sity in Health Hospital American 38. Am eri can Co ll eg e of Heal thc ar e Executives, Asso ci ati on, Institu fo r Heal th car e Leadership. Man agem en t, Nat io nal Center Does Your Hospit al Reflec t the Com munit y it Serves?: go, IL: Ame ri ca n Hosp ital Assoc iation; Apri l Chica A Diver sity and Cul tu ra l Prof ici ency Ass ess me nt Tool for Lea der s. pdf/diversitytoo l.p df . Accesse d Februar 20 04 . Avail ab le at : www .ah a.o rg/ah a/content/2004/ y 19, 2008. a Cultur ally Compet ent System 39. Adapte (Vo lume d from Cross T, Baz ro n B, Denn is K, Is aacs M. Towards of Ca re at: I) . Geo rge tow n Un iv ersi ty Cent er for Child and Hum an Develop ment , Wa shin gt on, DC; 1989 . Available http s:/ /ww w.omh 12, 200 6. December rc .g ov /t empl at es/ br ows e.as px?1 v1=2 &lv1 ID= 107 . Acc essed 40. Je ze wski MA. Cultural bro kerin g in migran Wes t J Nur s Re s. 1990 Aug;12(4):497-513. t farm wo rker healt h car e. Culturally Comp et ent Re hab ili tation Se rvices to Fo reign- born Je ze wski MA, So tn ik P. Cult ure Broker in g: Providing o, Ne w Yo rk; 2001. Buffal Pe rs ons. ms. Bridging 41. Ad apt ed from l Di vid e in Healt h Care Settings : The Es sent ia l Role of Cu ltural Brok er Progra the Cultura an d Services Resources Dev el ope d for the Nat io nal Healt h Ser vice Corps of Heal th Pr ofes sio ns, Health Bureau Ad mi ni st ra tion , U. S. Depa rt ment of Heal th and Hu man Serv ices by Natio nal Cen ter for Cul tural Compet en ce, t. Sprin g/S um mer 200 4. Geo rget own Un ive rsit y Cent er fo r Chi ld an d Hu man Developmen 56 e Guide for Hea lt h Car e Providers. A. Health 42. Ad apted fro m Sampson Lang uag e Ser vices Resourc The National Oct ober 2006. in Heal th Care. La w Pro gr am and the Nat ional Co unci l on Interpreting Th e Joint Comm 43. Th e Joint Com miss ion. Oakbrook Terr ace, IL: The Joint is sion Stand ar ds for Hos pi ta ls. Co mm is sio n; 2008.

57 AP PENDI XB: Glo ss ar y ra ci al an d ethn ic diffe ren ces in heal th car e di sp ari ties : for th e purp oses of thi s re po rt, we have bili ng ual sta ff: tha t are no t attr ibu table to oth er kno wn fac tor s [1] . use d this te rm to refer to individua ls who have some degree e. tha n one languag of pr oficie ncy in more an in divi dua l who assi st s with la bor and af ter dou la: in a dual role, wh o serve Bi li ng ual st aff in cl udes those chi ldbirt h. prov id ing inter preter service in additio n s for the ho spital to their pri mar y po si tion. a cr iti ca l comp tio n: ive co mmunica effect on ent to th e pa tie nt’ s under sta ndi ng of th e info rme d co nsen t process, th e cap acity to funct ion effe ctiv ely having com pet ence: par tic ipati on in his or he r ca re, un der sta ndi ng of all as an in divi dual and an org ani zatio n wi thin the context inf or ma ti on prov ide d to him or her, an d ability to fulfill of the cu ltu ra l be liefs , beh avi ors, and ne ed s prese nted by the re sp onsi bil iti es relate d to his or he r care. In or de r for peop le and th eir co mmuni ties [39 ]. com mu nic atio n to be eff ec tiv e, the in form at ion provi ded must be comp lete , acc ur ate, ti me ly, unam big uous , an d lin ks, or who bri dges, an individual cul tura l br oker: sto od by the pati ent. under g cultu ral or perso ns of differin medi ates be tw ee n groups bac kgroun of reduc in g confl icts, pro - ds fo r the purpose di etary law s which regul ate th e prep ar ati on of fo od ha la l: duc ing chang e, or adv ocating on beha lf of a cul tural group s. in accord ance with Mu sli m pri ncip le s and tec hnique l pro - or pers on [40 ]. Cult ural bro kers can also be medica wh o dr aw upon cultural fessi onals science an d health Ima m: a Mus lim relig ious lead er ; pr ayer lea der of a mosque. and wit h th e patient know ledg e and sk ills to negotiate ou tc om e [4 1]. an effective he alt h syste m toward in te rp ret er /inte rpr et at ion/ in te rpre ti ng : is int er pre ter an a per son who rend ers a mes sag e spoke n/ si gne d in one lan - the ability of hea lth care provid ers cult ur al co mpe ten ce: gu ag e into one or mor e lan gu ag es . Th e prac tic e of int er- to und erstan and heal th ca re or gan izations d and respond is dis tin guis hed in th is re po rt fro m tr an sl ati ng to pr etin g effe ctiv ely to the cultural and la ngua ge needs brought by in clud e on ly spo ke n/ si gn ed lan gu age . re fers to In te rp re ti ng l compe Cultura - ca re enco unter. th e pati ent to the health refers to the per son int er pre ta ti on; inte rprete r th e proc ess of and thei r personnel te nce re qu ires org anizations to: 1) val ue ing th e in ter pre tation [42]. who is provid th emsel ves; 3) mana ge the dynam ics of dive rs ity; 2) assess dif fere nce; 4) acqu ir e and institu tio nal iz e cultural kno wl - la ng uag e servi ces : fo r pu rpo ses of th is report , lang uage edge ; and 5) ada pt to diversity and the cul tural contexts of se rvi ce s re fe rs to those mech ani sms use d to fa cili tate co m- individ ual s and co mmuni [17 ]. ties served mun ica ti on wit h indi vi dua ls who do not spe ak Engli sh and th ose wh o are deaf or hard of he ar ing. These ser vice s can cul tura lly an d linguist ap prop riate se rvices : ically incl ude in- per so n int er pretat io n usin g a pr ofes sio nal hea lth hea lth care ser vices that are res pectf ul of and responsive inter pre ting sys - care int erp re ter, bil ingu al sta ff, or remote to cultu ral an d lang uage needs [15 ]. tem s such as te lep hone ng . or vid eo med ica l int erpreti Lang uage serv ice s als o ref er to pro ces ses in place to provid e int egrat ed patterns of huma n behavi or that cul tur e: tr ansl atio n of wri tten ma teri al s or signa ge. , co mmunications, thoughts inclu de the lan guage, and in sti tutio ns of racia l, act io ns, cust oms, belief s, values, a leg al concep t (L EP): lim it ed Engli sh prof ici ency group s [39]. ethni c, relig io us , or social referring to a level of En gli sh pro fi cienc y th at is in suf fi- 57 an ci ent to ensur e equ al ac ces s to public servic es without a tradit io na l folk hea ler in some ero : Lati n curand and /or ted to cur in g physical Americ an cu lt ures dedica int er prete r; the ina bi li ty to sp eak , re ad, wr ite, or und er - spi ri tu al il lne sses . st an d Eng lis h at a le vel tha t per mi ts an indi vi dua l to inte ract ef fec tiv ely wi th hea lt h ca re pro vi de rs or soci al ser vi ce ag enci es [20].

58 APPE ND IX B: Glos sary tr an sl at or/tr ans lat ion/ tra nslat in g: a tra ns la tor is a per - Natio na l Sta nda rds on Cul turall y an d Lin guisticall y son who co nv erts wr itte n te xt in one lang uag e into an ot her Appro the co llective (CLAS pri ate Se rvices stan dar ds ): Tran sla ti on lang ua ge . is dis tin gu is he d from inter pretati on services set of cu ltur ally and lingu is tica lly appropriate to re fer to wr itte n lan gu age [42 ]. tes, gui delin es , an d recom mend ations (CL AS) manda Depa rtm ent of Health issued by the Uni ted States and inte rp re ti ng car ried out vi deo medical int erp re tin g: Human Se rv ic es Of fice of Minor it y He alt h int end ed to remote ly us in g a vide o came ra th at en abl es an interp ret er in form , guid e, an d fac ilita te requ ired an d recom mended in a rem ot e locatio n to bo th see an d he ar the parti es fo r pr act ice s rela te d to cultu rall y and lingui sti cal ly app ropriate wh om he or sh e is in ter pr et ing via a te le vis ion mo nitor. hea lth se rvic es [15]. Th e int er pre tat io n is re laye d to the pri nci pal pa rties by spe ake rpho ne or th ro ugh heads ets. Two -way in ter ac tive prof es si onal health an indiv idu al with car e in terpreter: telev ision can als o be used so th at the other parti es ca n th e app ro pr ia te tra in ing and ex perienc e to int erpret wit h in te ract with the inte rpre te r as th ou gh fac e-to -fac e [18]. and who ad he res to a co de of co ns is te ncy an d ac curacy pro fes si on al et hics [18]. cted occur re nce invol ving sen ti ne l eve nt : an unexpe or the death or ser ious phy sical or psych olo gi cal injury, los s of ri sk th ereo f. Se ri ous injur y spec ifica lly includes es includ or the risk th er eof limb or funct io n. Th e phr ase for wh ic h a recu rrenc e woul d carry an y proce ss vari ation a si gni fica nt cha nce of a ser io us adve rse ou tcome [43] . shaman: a memb er of cert ain trib al societ ies who ac ts as a medi um be twe en th e natu ral an d supern atu ral wo rld . te le ph one in terpr eting : interp ret ing car ri ed out rem ote ly, with the in terpre to te r co nn ect ed by tele phone the princ ip al part ies, typical - ly pr ov id ed th ro ugh speaker pho nes or headse ts. In heal th care se tt ings, the prin cipal par ti es (e. g. , do ct or and pati en t) are nor mally in the same room, but telepho ne inte rp ret ing can be used to serve ind ivi duals who are also conn ec te d to each ot her only by tel eph one [18 ]. 58

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