1. One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations
Amy Wilson-Stronks, MPP, CPHQ
Principal Investigator
Hospitals, Language, and Culture study
Division of Standards and Survey Methods
The Joint Commission
2008 MIAB Conference
The $ and Sense of Culturally Effective Care:  Access, Communication, and Commitment
October 31, 2008

2. Today’s Journey Through the Eyes of a Patient – Meet Juan Lopez
60-year-old Mexican immigrant
Doesn’t speak English
Limited experience with the U.S. health care system
12-year-old English-speaking daughter Juanita

3. Our Story Begins…
Juan Lopez presents to Hospital X’s Emergency Department, accompanied by his daughter Juanita.
He is writing in pain and clutching his stomach.
He declares to the triage nurse,
“!Mi vecino me puso una brujeria!”

4. Who Juan Lopez Encounters:
Triage nurse
Emergency department physician
Emergency department nurse
Radiology tech
Medical surgery unit for recovery

5. Ideally, how would staff communicate with Juan Lopez at your organization?

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

7. Communication is the Cornerstone of Patient Safety

8. The Need for Accurate Information
Assess patient needs
Determine diagnosis/prognosis
Provide Treatment
Obtain consent
Educate/Inform
Hand-off communications

9. Multiple Players in Communication
Patient/family
Physicians
Nursing
Pharmacy
Physical Therapists
Speech Therapists
Occupational Therapists
Social Workers
Psychologists
Lab
Imaging
Billing

10. Factors That Can Inhibit Communication Abilities
Hearing impairment
Visual impairment
Cognitive Limitation
Intubation
Disease (ALS, Stroke)
Health Proxy
Culture
Literacy
Language

11. Poor Communication Impacts Patient Safety
Communication vulnerable patients are at increased risk for:
Serious medical events (Cohen et al., 2005)
Sentinel events (The Joint Commission, 2007)
Poor medication compliance/ adherence (Andrulis et al., 2002; Flores et al., 2003)

12. Root Causes of Sentinel Events12

13. Hospitals, Language, and Culture: A Snapshot of the Nation (HLC)
Cross-sectional qualitative study
Three Research Questions:
What are the challenges hospitals face providing care to diverse patient populations?
What are hospitals doing to address these challenges?
Are there any promising practices that can be replicated to improve care?

14. HLC Sample Hospitals (n=60)
Region (representing 32 states)
West 21
Midwest 12
South 17
Northeast 10
beds: 18
Rural: 15
25-99 beds: 10
Non-profit:32
300+ beds: 32
Urban: 35
Public: 15
Teaching/Academic: 22

15. HLC Study Methodology
Cross-sectional qualitative study of 60 hospitals
2 samples of 30 hospitals
In-person administrative interviews
CEO (one-on-one)
Leadership, Human Resources, Cultural and Language Services (3 groups of 3 representatives)
In-person clinical interviews
Patient-centered assessment interviews focused on a clinical case scenario (one-on-one)
Source: Hospitals, Language, and Culture Study, A.Wilson-Stronks et.al, 2008 15

16. Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings
Wide range of practices/interpretation of good practice
Gap between current practice and desired practice
Missing resources
Resources, processes not being used
Culture and language are challenging issues to address
Download the report free:
patientsafety/hlc

17. Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings
More focused efforts on language than culture
Data collection and use is inconsistent across and within hospitals
Need for greater clarity in Joint Commission standards regarding effective communication
Download the report free:
patientsafety/hlc

18. Leadership Support: A Key to Success
Insights from Hospital CEOs

19. Recommendations: The Role of Leadership
Establish a centralized program to coordinate culture and language services
Make the commitment to culturally and linguistically appropriate care highly visible
Have internal multidisciplinary dialogues
Research is needed to better understand what drives hospital CEOs who embrace culturally and linguistically appropriate care
Source: Wilson-Stronks A, Galvez E. Exploring cultural and linguistic services in the nation’s hospitals: A report of findings. Oakbrook Terrace, IL: The Joint Commission; 2007. 

20. Recommendations: Collecting and Using Data
Implement a uniform framework for the collection of data on race, ethnicity, and language.
Stratify service and technical quality measures such as those reported through the Hospital Quality Alliance, by language, race, and ethnicity
Source: Wilson-Stronks A, Galvez E. Exploring cultural and linguistic services in the nation’s hospitals: A report of findings. Oakbrook Terrace, IL: The Joint Commission; 2007. 

21. Recommendations: Provision of Language Services & Workforce
Establish and implement written policies that do not permit the use of family members/ad hoc individuals to interpret
Assess English and target language proficiency of all individuals used to interpret
Incorporate language service programs into safety and quality efforts - PI structures and tools
Provide ongoing training on how and when to access language services
Source: Wilson-Stronks A, Galvez E. Exploring cultural and linguistic services in the nation’s hospitals: A report of findings. Oakbrook Terrace, IL: The Joint Commission; 2007. 

22. Recommendations: Provision of Care & Community Engagement
Formalize processes for translating written materials (patient rights, informed consent, etc.)
Use health care interpreters and cultural brokers to facilitate communication
Take advantage of internal and external resources available to learn about cultural beliefs
Make staff aware of the tendency toward stereotyping to avoid assumptions about patients
Make use of community resources through networks, collaborations, and partnerships
Source: Wilson-Stronks A, Galvez E. Exploring cultural and linguistic services in the nation’s hospitals: A report of findings. Oakbrook Terrace, IL: The Joint Commission; 2007. 

23. How Can the Findings Be Used?
The recommendations recognize that an integrated effort among hospitals, policymakers, and researchers is required.
Can use findings as benchmark and use recommendations to conduct gap analysis.

24. Hospitals, Language, and Culture: A Snapshot of the Nation
Cross-sectional qualitative study
Three Research Questions:
What are the challenges hospitals face providing care to diverse patient populations?
What are hospitals doing to address these challenges?
Are there any promising practices that can be replicated to improve care? 24

25. One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations
Released April 21, 2008
Download a free copy of the report on HLC website
Thematic framework derived from current practices in 60 hospitals
Download this report free at: 25

26. Theme 1 - Building a Foundation
Developing a supportive infrastructure for cultural competence
Cultural competence in organizational planning
Developing policies for cultural competence
Integrating culture and language (C&L) into organizational systems
Recruiting and sustaining a diverse workforce
Creating a high-level task force
Structuring budget systems for culturally and linguistically appropriate care
Integrating cultural competence into patient care
Providing appropriate language services
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 26

27. Theme 1 - Building a Foundation
“It’s one thing to put it in a mission and vision statement and plaster it on the wall and to say we serve all people in the community regardless of ethnicity or race; it’s another thing to actually do it.”
–CEO from a northeastern hospital
“I think the biggest challenge is making certain that staff and employees [practice] cultural sensitivity. This is a people business and as much as the CEO might issue an edict…[cultural sensitivity] does not happen unless you invest in your employees.”
–CEO from a western hospital
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 27

28. Theme 2 - Collecting and Using Data to Improve Services
Assessing the need for C&L services
Collecting community- and patient-level data
Monitoring C&L service utilization
Collecting data on service use
Building upon C&L service utilization data
Using data to improve C&L services
Establishing a baseline of services
Obtaining patient feedback
Stratifying data by demographic variables
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 28

29. Theme 2 - Collecting and Using Data to Improve Services
“Collection of data is critical. Data shows you who your population[s] [are] and what languages these populations speak. Further [scrutiny] of the data allows the facility to see what services they are most apt to seek…. Data allows [human resources] to conduct an annual comparison of employee mix to community and patient load. If the patient data does not proportionately match the community data, then the facility must ask if there is a reason why that population is not accessing services.”
–HLC Technical Advisory Panel member
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 29

30. Theme 3 - Accommodating the Needs of Specific Populations
Staff awareness through training, dialogue, and support
Training on effective communication, cultural competence
Providing staff with educational resources
Creating an environment that meets specific needs
Enhancing the hospital’s physical space
Adapting services to address cultural beliefs
Helping patients manage their care
Navigating the health care system
Providing patient education
Establishing centralized programs that meet specific needs of large populations
Culturally and religious/spiritually centered
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 30

31. Theme 3 - Accommodating the Needs of Specific Populations
“[The doula program] came out of dialogue with women from the community that we were able to bring in [to] talk about their birth practices [and] our birth practices…. We literally sent vans out to go pick women up and bring them here to have a dialogue. It was as informal as that. It [developed] into the doula program that we [now] have.”
–A member of C&L services from a midwestern hospital
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 31

32. Theme 4 - Establishing Internal and External Collaborations
Working together within the hospital
Establishing a cultural diversity committee
Bringing diverse stakeholders together
Building bridges with other hospitals
Sharing, pooling existing resources
Engaging the community
Community partnerships to create a diverse workforce
Using community leaders to bridge cultural barriers
Becoming an active member of the community
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 32

33. Theme 4 - Establishing Internal and External Collaborations
“We are part of a local collaborative, where six or seven different health care systems have come together and said, ‘We don’t all need to translate all of our diabetic and education information into these six or seven languages. Why don’t you take on doing half of those, and we’ll do half of those, and let’s take our letterhead off of that information.’ We can use that information across the system.”
–A member of C&L services from a midwestern hospital
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 33

34. Supporting References for Practices
Hospitals, Language, and Culture: A Snapshot of the Nation’s Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings
American Medical Association, Ethical Force Program’s Improving Communication—Improving Care: How Health Care Organization Can Ensure Effective, Patient-Centered Communication with People from Diverse Populations
Office of Minority Health’s National Standards for Culturally and Linguistically Appropriate Services in Health Care
The Joint Commission’s “What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety 34

35. The Big Question: How can the practices in this report help my organization better serve our diverse patients??

36. Chapter 8: Tailoring Initiatives to Meet
the Needs of Diverse Populations
There is no “one size fits all” solution for cultural competence. Each organization is unique.
Organizations need to:
Identify the needs of the population served
Assess how well needs are met through current systems
Bring people together to explore C&L issues
Make assessment, monitoring, and evaluation of needs and services a continuous process
Implement a range of practices spanning all 4 themes of this report in a systemic manner
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 36

37. Methods for Self-Assessment
Focus groups
In-services
Lunch meetings
Seminar series
Small-group interviews
Staff retreat
Targeted interviews
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 37

38. Potential Participants
Chief executive, medical, nursing, operating officers
Community members
Dietary services
Diversity officer
Financial assistance/ billing staff
Hospital chaplain
Human resources director
Information technology staff
Intake staff
Language services coordinator
Medical and nursing staff
Patient advocates
Patient safety officer
Patients and families
Quality improvement officer
Recruiter
Risk management officer
Social services
Staff/clinical educator
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 38

39. from Self-Assessment Tool
Sample Questions
from Self-Assessment Tool
Building a Foundation
How does our leadership currently support the provision of culturally competence care?
Collecting and Using Data to Improve Services
How have we assessed the C&L needs of the community? Our patients?
Accommodating the Needs of Specific Populations
What aspects of the physical environment have been evaluated to determine whether they meet specific patient needs?
Establishing Internal and External Collaborations
What community organizations or networks, religious leaders or chaplains, or traditional healers can we collaborate with to meet patient needs?
Source: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 39

40. Field Test of the Self-Assessment Tool
2-hour workshop with an organization’s cultural diversity committee
Questions from Theme 1 – Building a Foundation
3 facilitated small group sessions
Large group discussion of responses
Received positive feedback (n=25)
Participants indicated it was a useful exercise
The tool helped people learn more about their organization
Overall the questions were understandable 40

41. We want your feedback!
Evaluation form available as an electronic survey on HLC website; paper copies in published reports
Organizations are encouraged to provide feedback after using the self-assessment tool:
How did your organization use the tool?
Who was involved?
How useful do you feel the tool is?
What type of organization are you from?
Where is your organization located?
Additional comments and suggestions for improvement
Survey available at: 41

42. Summary – One Size Does Not Fit All
Thematic framework derived from current practices in 60 hospitals
Self-assessment tool to tailor initiatives to meet the needs of diverse patient populations
Cultural competence is an ongoing journey - hospitals should assess and re-assess the services they provide
Download this report free at: 42

43. Evolution of Joint Commission Standards Supporting CLAS
Identification of certain rights for all patients
Increased patient awareness related to patients’ participation in care
Cultural competence is more than a patients’ rights issue; it is critical to safety and quality of care

44. Developing Hospital Standards for Culturally Competent Patient-Centered Care
18-month standards development project (August 2008 through January 2010)
Project will explore how diversity, culture, language, and health literacy issues can be better incorporated into current Joint Commission standards or drafted into new requirements 
Standards will build upon previous studies and projects, including the research framework from the HLC study and evidence from the current literature.

45. Developing Hospital Standards for Culturally Competent Patient-Centered Care
A multidisciplinary Expert Advisory Panel will provide guidance regarding principles, measures, structures, and processes that will be the basis of standards
Collaboration with National Health Law Program (NHeLP) to develop an implementation guide to prepare organizations for new standards

46. For More Information
Hospitals, Language, and Culture study website:
Available:
Downloadable reports
HLC study information
Links to other websites
Resources
Amy Wilson-Stronks