1. Federal and State Requirements and Guidelines Impacting Cross Cultural Health Care
Cross Cultural Health Care Conference II
October 7-8, 2011
Hyatt Regency Hotel
Honolulu, Hawaii
Serafin Colmenares Jr., Ph.D.
Office of Language Access
Department of Labor and Industrial Relations
State of Hawaii

2. Culture
Norms, values and patterns of behavior which govern time, spatial, personal relationships and attitudes.
Knowledge and shared values among members of a particular group.
The way we are; the way we do things.

3. Cultural Competency
– a set of values, behaviors, attitudes, and practices which enables individuals and organizations to work effectively regardless of culture.

4. The Need for Cultural Competence
Address ethnic, cultural and linguistic diversity
Eliminate health disparities
Improve patient safety and health outcomes
Enhance workplace environment
Meet accreditation mandates

5. Communication Communication is the heart of medical practice
More than 70% of information on which physicians base their diagnoses come from the history and physical exam
One of the biggest barriers to high-quality health care for millions of U.S. residents has nothing to do with medicine.
It has to do with language.
(Ira SenGupta, 2010)

6. Barriers to Communication in Health Care
Linguistic: differences in languages spoken
Barriers of register: complex language and complex procedures
Cultural barriers: difference in culture that lead to dissimilar expectations and behavior
Systemic barriers: complexity of health care system
(Ira SenGupta, 2010)

7. Why Language Services Are Important
Health disparities
Access to care
Quality of care
Cost of care
Risk management
Federal and state requirements
(Ira SenGupta, 2010)

8. Physician Liability/Malpractice Lawsuits
Individual providers are liable for malpractice if they practice medicine on patients with whom they cannot communicate clearly.
2010 UC-Berkeley Study – 35 malpractice claims ( ); paid $2.289m in damages and $2.793m in legal fees due to failure to provide competent interpreters and to translate important documents.

9. Federal and State Mandates and Guidelines
Office of Minority Health (OMH) 14 Culturally and Linguistically Appropriate Services (CLAS) standards
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and National Committee on Quality Assurance requirements
Civil Rights Act of 1964, Title VI
Executive Order of 2000
2010 Patient Protection and Affordable Care Act
Hawaii Language Access Law, Hawaii Revised Statutes, Chapter to 37

10. National Standards for Culturally and Linguistically Appropriate Service (CLAS) in Health Care (Office of Minority Health, DHHS)
Primarily directed at health care organizations, but individual providers are encouraged to use the same to make their practices more culturally and linguistically accessible.
Should be integrated throughout an organization and undertaken in partnership with the communities being served.

11. CLAS Standards
Health care organizations should ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.
Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.
Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

12. CLAS Standards (cont’d)
Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.
Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.
Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).

13. CLAS Standards (cont’d)
Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.
Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.
Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction Assessments and Outcomes-Based Evaluations.

14. CLAS Standards (cont’d)
Health care organizations should ensure that data on the individual patient’s/consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated.
Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.
Health care organizations should develop participatory, collaborative partnerships with communities and utilize a community and patient/consumer involvement in designing and implementing CLAS-related activities.

15. CLAS Standards (cont’d)
Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.
Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS Standards and to provide public notice in their communities about the availability of this information.

16. CLAS Standards (cont’d)
Standards 4, 5 and 6 are CLAS mandates (current Federal requirements for all recipients of Federal funds)
Standards 1, 2, 3, 8, 9, 10, 11, 12 and 13 are CLAS guidelines (activities recommended by OMH for adoption as mandates by Federal, State, and national accrediting agencies)
Standard 14 is CLAS recommendation (suggested by OMH for voluntary adoption by health care organizations)

17. JCAHO Guidelines
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance have adopted guidelines specifying the need for patient education information and consent documents to be written in such a way that patients can understand them.

18. Civil Rights Act of 1964
Title VI – prohibits discrimination on the basis of race, color or national origin in any program or activity that receives federal financial assistance. Recipients must ensure that they provide LEP persons meaningful opportunity to participate in their programs and services and benefits. Requires that recipients provide oral and written language assistance at no cost to the LEP person.

19. Executive Order 13166
“Improving Access to Services by Persons with Limited English Proficiency,” which requires federal agencies and their recipients to assess and address the needs of otherwise eligible persons seeking access to federally conducted programs, who due to “limited English proficiency” cannot equally participate in, or benefit from, such programs and activities. Directs each federal agency or recipient to prepare a plan to improve access to federally conducted programs and activities by eligible LEP persons.

20. 2010 Patient Protection and Affordable Care Act
Provides that, to the extent practicable, federal health data collections will include culturally and linguistically-specific data on population served (Title XXXI, Section 3101).
Guidance and tools still to be developed.

21. Hawaii’s Language Access Law
Affirmatively address, on account of national origin, the language access needs of limited English proficient persons to ensure equal access to state and state-funded programs, services and activities.
Requires state and state-funded agencies to (1) assess the need for language services; (2) provide free oral language services in a timely and competent manner; (3) provide written translations of vital documents; (4) establish a language access plan and, for state agencies, designate language access coordinators to establish and implement their plans, and hire bilingual personnel for existing, budgeted, vacant public contact positions.

22. Hawaii Demographics
Out of Hawaii’s total population of 1.28 million, more than 23% speak a language other than English at home.
Out of those who speak a language other than English at home, more than 45% are limited English proficient (LEP).
Out of the total LEP population, more than 83% are Asian language speakers while more than 9% are Native Hawaiian and Pacific Island language speakers.

23. Hawaii Demographics
Of the total LEP population, 34% are aged 60 and above.
Almost 83% are foreign-born.
Almost 36% have less than high school education.
46% earn less than $15,000 annually.
58% are female.

24. In Closing…
To improve individual health and build healthy communities, health care providers need to recognize and address the unique culture, language and health literacy of diverse consumers and communities.
Effective health communication is as important to health care as clinical skills.
Federal and state guidelines are available in the provision of culturally and linguistically appropriate health services.

25. MAHALO NUI LOA!