Cultural Competence in Health Care:
Overcoming Language Barriers as a Strategy to
Improve the Safety and Quality of Health Care
Cheri Wilson, MA, MHS candidate, CPHQ
Quality Improvement Team Leader
The Johns Hopkins Hospital
This presentation will provide an overview of:
• The effects of language barriers on patient
safety and healthcare quality
• The needs of limited English proficiency
(LEP) patients
• The importance of using non-English
materials and providing access to
language services
• Experiences, lessons learned, and success
stories from Johns Hopkins Hospital and
other organizations
Video Clip
Scope of the Problem:
U.S. Demographics
• As the United States becomes
increasingly diverse, healthcare
organizations struggle to provide
culturally and linguistically appropriate
services (CLAS) for LEP patients
Scope of the Problem:
U.S. Demographics
• Almost 35 million U.S. residents are
foreign born.
• Almost 55 million people (19.7% of the
U.S. population) speak a language
other than English at home.
• More than 24 million people (8.7% of
the U.S. population) speak English less
than "very well" and are considered
Video Clip
Federal Mandates and Regulations
• Title VI of the Civil Rights Act of 1964
considers the denial or delay of medical care
due to language barriers to be discrimination.
• Similarly, any medical facility receiving
Medicaid or Medicare must provide language
assistance to LEP patients.
• In addition, The Joint Commission, which
accredits healthcare organizations, requires
that interpretation and translation services be
provided as necessary.
Federal Mandates and Regulations
• However, neither of these mandates includes
• The burden of the cost of language services
remains the responsibility of the provider.
– An American Medical Association (AMA)
survey found that the cost of interpreter
services ranged from $30 to $400 per hour,
while the average Medicaid office visit
reimbursement was only $30 to $50.
– Private payers generally do not reimburse
for interpreter services.
Federal Mandates and Legislation
• Two major impediments to providing
language services are:
– Lack of availability of qualified,
medical interpreters, and
– Inadequate funding
Patient Safety and Healthcare Quality
• Research studies have documented
that the safety and quality of healthcare
of LEP patients can be diminished due
to language barriers.
Patient Safety and Healthcare Quality
• One study found that in 46% of
emergency department cases, no
interpreter was used for LEP patients.
• In addition, only 23% of teaching
hospitals train physicians how to work
with an interpreter.
Patient Safety and Healthcare Quality
• A study analyzed 1,083 adverse incident
reports from six Joint Commission-accredited
hospitals for English speaking vs. LEP
patients for 7 months in 2005.
– This study found that a greater percentage
of LEP patients experienced physical harm
versus English-speaking patients, 49.1%
and 29.5% respectively.
– The LEP patients also experienced higher
levels of physical harm ranging from
moderate temporary harm to death, 46.8%
and 24.4% respectively.
Patient Safety and Healthcare Quality
• In an effort to provide language services,
healthcare providers have sometimes
resorted to drastic measures.
• At one hospital, the emergency room
used the Yellow Pages to find a restaurant
that spoke a particular language and
would ask one of the restaurant
employees to interpret over the phone.
Patient Safety and Healthcare Quality
• Other hospitals have used:
– untrained support staff,
– strangers found in the waiting room or
on the street,
– taxi cab drivers, etc.
Patient Safety and Healthcare Quality
• In many instances, a family member serves
as an interpreter, which raises privacy and
other concerns.
– For example, California State Senator
Leland Yee remembers translating for his
mother at the doctor's office when he was
only six years old.
• Several states have introduced legislation
forbidding children under sixteen from serving
as interpreters.
Patient Safety and Healthcare Quality
• Untrained interpreters are more likely to
commit errors in interpretation that can
lead to adverse clinical consequences.
Patient Safety and Healthcare Quality
• Concerns about untrained interpreters
– Lack of knowledge of medical terminology
and confidentiality,
– Their priorities may conflict with those of
the patients, and
– Their presence may inhibit discussions of
sensitive issues, such as:
• domestic violence, substance, abuse, psychiatric
illness, and sexually transmitted diseases.
Patient Safety and Healthcare Quality
• Occasionally, a bilingual healthcare
provider may be present.
• However, this is not without its problems
as well.
– For example, in one case, a mother lost
custody of her two-year old child who fell
off her tricycle because the doctor
misinterpreted two Spanish words (Se
pegó) as "I hit her" instead of "She hit
Patient Safety and Healthcare Quality
• Care can be compromised or delayed in
the absence of any language service
(trained or untrained).
• In other instances, the consequences
can be catastrophic.
Patient Safety and Healthcare Quality
• A health care team misunderstood an
eighteen year old man who said that he
was intoxicado.
– The team misunderstood the term to mean
"intoxicated" rather than “nauseated.”
– As a result, the patient was treated for a
drug overdose for thirty-six hours before
the doctors realized that he had a brain
– He ended up being a quadriplegic and his
family was awarded $71 million in a
malpractice settlement.
Video Clip
• What issues arose during this scenario?
Video Clip
• How was this scenario improved with
the assistance of a trained, staff
Best Practices:
The Johns Hopkins Hospital
• Per the JHH Interdisciplinary Clinical Practice
Manual (ICPM) policy, “PAS002: Interpreting
Services,” foreign and sign language
interpreters are available to patients.
– For foreign languages, call Johns Hopkins
International Services at 4-INTL (4-4685)
• On-site interpreters are available for the most commonly
spoken foreign languages during business hours
• After business hours, a 24/7 language line is available.
– For sign language, call Patient Relations at 410955-2273.
Best Practices:
The Johns Hopkins Hospital
• According to the policy, interpreters must be
provided to patients and/or family members
under the following circumstances:
– Obtaining the patient’s medical history;
– Explaining the plan of care and periodic updates
on the plan of care
– Discharge planning discussions
– Explaining procedures
Best Practices:
The Johns Hopkins Hospital
• According to the policy, interpreters must be
provided to patients and/or family members
under the following circumstances:
– Obtaining consent;
– Providing patient education, including discharge
instructions; and
– Having discussions about advance directives.
Best Practices:
The Johns Hopkins Hospital
Best Practices:
The Johns Hopkins Hospital
Best Practices:
The Johns Hopkins Hospital
• Johns Hopkins International has
translated certain patient education
materials into various foreign
Best Practices:
The Johns Hopkins Hospital
Best Practices:
The Johns Hopkins Hospital
• In addition, Patient Education materials
are available in English and Spanish in
Micromedex CareNotes™.
Best Practices:
The Johns Hopkins Hospital
• National Standards on Culturally and
Linguistically Appropriate Services
• Limited English Proficiency: A Federal
Interagency Website
• Hablamos Juntos: Language Policy and
Practice in Health Care
– Also see: Universal Symbols in Health
• Speaking Together: National Language Services
• National Health Law Program: Language Access
in Health Care Statement of Principles
• HRET Disparities Tool Kit: A tool kit for collecting
race, ethnicity, and primary language from
• Diversity Rx
– Quality Healthcare for Culturally Diverse
Populations Conference
• A Patient-Centered Guide to
Implementing Language Access
Services in Healthcare Organizations
• Joint Commission: Hospitals, Language, and
Culture: A Snapshot of the Nation
• Joint Commission: One Size Does Not Fit All:
Meeting the Health Care Needs of Diverse
• Oral, Linguistic, and Culturally
Competent Services: Guides for
Managed Care Plans
• Providing Oral Linguistic Services: A
Guide for Managed Care Plans
• White Paper: “For the Health Care
CEO: Thinking about Language Access
in Health Care” –
by Edward L. Martinez, MS
• Open invitation to comment on the
National Quality Forum’s proposed
“Framework and Preferred Practices for
Measuring and Reporting Cultural
Public comments due by November 5, 2008.
Video Clip
• To order the video, Breaking Down the
Language Barrier: Translating Limited
English Proficiency into Practice
– Contact the Department of Justice Civil
Rights Division’s Coordination and Review
Section at (202) 307-2222 or
– CDs and associated materials are
available for free
For additional information, contact Cheri Wilson at: or 410-502-6025.

5-Cultural Competence and Health Care