Cross-Cultural Communication in Health Care:
Building Organizational Capacity

Broadcast Slides

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Slide 1: Cross-Cultural Communication in Health Care: Building Organizational Capacity
Satellite Broadcast - June 4, 2003
Sponsored by the HRSA Center for Health Services Financing and Managed Care and the Office of Minority Health, DHHS.

Slide 2: Common Foreign Languages in US
Spanish, Chinese, French, German, Tagalog, Italian, Vietnamese.
Source: 2000 Census.

Slide 3: Understanding the Language
A physician who understands the language of patients produces better patient self-reported physical functioning, psychological well-being, health perceptions, and less pain.
Source: Perez-Stable EJ et al. Medical Care, 1997.

Slide 4: Untrained Interpreters
- Omitted questions about drug allergies
- Omitted instructions on the dose, frequency, and duration of antibiotics and rehydration fluids
- Instructed a mother not to answer personal questions
Source: Flores G et al. Pediatrics. 2003.

Slide 5: Accurate Interpretation Equals Clinical Quality
Reduces medical errors and increase patient safety
Increases patient compliance
Increases patient satisfaction
Improves primary care utilization

Slide 6: Membership by Language (Alameda Alliance for Health)
Total Population: 85,348
55%: English
45%: Chinese, Cambodian, Vietnamese, Spanish, Asian/Pacific Islander, Farsi, Other

Slide 7: The Virtue Matrix
Frontier
- Strategic: Profit making; Results in postive reaction from owners and constituencies
- Structural: Contrary to owners' interest
Civil Foundation
- Choice: Dictated by norms and customs of industry/society
- Compliance: Required by laws, regulations or contracts

Slide 8: Linguistic Competence: Business Value
Increase market share
Maximize retention rates
Avoid or reduce costs
Reduce medical errors
Increase primary and preventive care
Increase patient satisfaction
Increase compliance

Slide 9: Linguistic Competence: Business Value (continued)
Reduce ER use
Reduce unnecessary admissions
Decrease costs for diagnostic testing

Slide 11: Cultural Competence Definition
A set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals that enables effective interactions in a cross-cultural framework.

Slide 12: Linguistic Competence Definition
Providing readily available, culturally appropriate oral and written language services to Limited English Proficiency (LEP) members through such means as bilingual and bicultural staff, trained medical interpreters, and qualified translators.

Slide 13: CLAS: # 4
…offering and providing 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.
Source: National Standards for Culturally and Linguistically Appropriate Services

Slide 14: CLAS: # 5
…providing to patients/consumers, in their preferred language, both verbal offers and written notices informing them of their right to receive language assistance services.
Source: National Standards for Culturally and Linguistically Appropriate Services

Slide 15: CLAS: # 6
…assuring 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.
Source: National Standards for Culturally and Linguistically Appropriate Services

Slide 16: CLAS: # 7
…making available easily understood patient-related materials and posting signage in the languages of the commonly encountered groups and/or groups represented in the service area.
Source: National Standards for Culturally and Linguistically Appropriate Services

Slide 17: Planning Language Services: Social, Political and Economic Factors
Different geographic/community values and styles of interaction
Willingness and ability to take risks
Communities contain various cultures, languages, ages and abilities

Slide 19: Strategic Goals (Sunset Park Family Health Center Network)
Increase patient satisfaction
Increase staff satisfaction
Provide staff training
Create a managerial infrastructure
Reduce cost and increase efficiency

Slide 20: Providing Oral Linguistic Services: A Guide for Managed Care Plans
Published by the Centers for Medicare & Medicaid Serivces and the Agency for Healthcare Research and Quality

Slide 21: Planning Language Services: Six Steps
1. Examine linguistic needs
2. Assess organizational capabilities
3. Identify points of contact
4. Consider different language strategies
5. Assemble linguistic services plan
6. Monitor linguistic services and strategies

Slide 22: Planning Language Services: Three Guiding Principles
1. Build reporting and refinement into each step
2. Learn from your mistakes
3. Celebrate successes, small and large

Slide 23: Sources of Language Data
Population-level language data
Census, school or local planning district data
Member or patient population-level language data

Slide 24: Surveys
Easy to analyze
Can track results
Less expensive

Slide 25: Drawbacks to Surveys
Trust is an issue for communities of color
May have poor response due to resistance
Difficult to translate linguistically
Nuances are lost

Slide 26: Focus Groups
Allow sharing of impressions, emotions and values
Surfaces new information
Promotes sensitivity and understanding of issues

Slide 27: Drawbacks to Focus Groups
Not representative
Heterogeneity of community is lost
Cannot measure results quantitatively or generalize

Slide 28: Self-Assessments
In-depth, qualitative comments are added
Teams can work together
Raises awareness

Slide 30: Task Force Recommendations and Action Plan
(Sunset Park Family Health Center Network)
More bilingual staff should be hired
Training on medical interpretation skills
Training for providers on how to use interpreters

Slide 32: Mistakes by Inadequately Trained Interpreters
An average of 31 mistakes per doctor-patient visit
Two-thirds could have negative consequences for patients
Source: Flores G et al. Pediatrics. 2003.

Slide 33: Consequences for Patients with Language Barriers
In the emergency room 28 minutes longer
More likely to be admitted to the hospital
More likely to receive IV fluids
Billed charges an average of 39% more
Source: Hampers L. Pediatrics. 1999

Slide 34: Written Points of Contact Unconnected to Oral Communication
Benefits information
Medical Records
Claims and billing

Slide 35: Translation "Don'ts"
Don't use computer programs with automatic translations
Don't overburden your bilingual staff
Don't rely on interpreters to "sight translate"

Slide 36: Overlooked Written Points of Contact
Preparations for diagnostic procedures
Informed consent forms
Side effects information
Medication bottle labels

Slide 37: How to Assess for Points of Contact
Member visit surveys
Provider and staff surveys
Focus groups
Medical claims information
Billing records

Slide 38: Possible Criteria for Selecting Language Strategies
Most important to patient and community groups
Achievable in close time line
Aligned with overall organizational business goals
Accomplished with local resources or acquirable resources
Supported by staff groups

Slide 40: Strategies - La Clinica del Pueblo (continued)
Link training on immigrant culture and background to linguistic access training
Advocate and educate to obtain buy-in and support for linguistic access plans
Use language access cards identifying language and requesting an interpreter

Slide 41: Methods of Interpretation
Consecutive
Simultaneous
Telephonic (remote vs. local)

Slide 42: Value in Developing a Written Plan
Assists in thinking through and affirming steps
Provides a map
Provides documentation

Slide 43: Components of Plan
The business case
Linguistic needs
Current linguistic capabilities
Points of contact
Gaps in linguistic services

Slide 44: Components of Plan (continued)
Proposed strategies and services
Implementation of strategies and services
Budget for implementation
Appeals and grievances
Monitoring and maintenance
Summary

Slide 45: Ambulatory Care Report Card: 1996 - 2002 (Sunset Family Health Center Network)
Quality of Service
- 80% to 93% overall patient satisfaction
Quality of Care
- 56% decrease in pediatric asthma admissions
- 82% to 97% increase in use of appropriate asthma medications

Slide 47: Five Key Areas of Monitoring
1. Competency of the interpreter
2. Adequate screening and training practices
3. Accountability for assessing and documenting competency
4. Code of ethics
5. Competency of bilingual staff used as interpreters

Slide 48: Monitoring Methods
Utilization statistics
Compliance with requirements
Complaints data
Member and patient satisfaction surveys

Slide 49: Monitoring Methods (continued)
Staff and provider satisfaction surveys
Satisfaction surveys of bilingual staff used as interpreters
Clinical outcomes and impact

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Send questions about the Satellite Broadcast to George Smith at GSmith@hrsa.gov