Brunilda Torres, LICSW
Director, Office of Multicultural Health
Massachusetts Department of Public Health
Strategies for Protecting Patient Safety
September 12, 2003
[email protected]
Office of Multicultural Health
To promote the optimal health and well
being of immigrant, refugee and racial and
ethnic minority communities statewide
To ensure that Massachusetts’ public health
frameworks are inclusive of and responsive
to the needs of these communities
Goals
•
•
•
•
Background from my perspective
Health Disparities
CLAS
Interpreter Services
History: improving health of population
• 1789- 1st mortality tables: Rev
Wigglesworth
• 1900 Life expectancy: 47 years
• 1900 main causes of death identified
• 1950’s life expectancy 68
• 1960’s and ‘70’s research: improved
knowledge about predisposing conditions
• These occurred throughout our national
history that included slavery and Jim Crow–
“separate but equal”
History
Civil Rights Act of 1964
“No person in the United States shall, on
ground of race, color, or national origin, be
excluded from participation in, be denied
the benefits of, or be subjected to
discrimination under any program or
activity receiving Federal financial
assistance.”
History
• OMB directive 15 1977, revised in 1997 to
include sub populations
• Healthy People Initiative: improve health of
country
– 1979: Healthy People: The Surgeon General’s
Report on Health Promotion and Disease
Prevention--national goals
– improve data infrastructure
– 1980: Promoting Health/Preventing Disease:
Objectives for the Nation-- identified disparities
– Healthy People 2000: reducing disparities
among populations revised
History
• Our understanding around vulnerability has
changed
• Federal supports: legislation and guidance
• Frameworks develop to assist creation of
local actions to addressing the needs of
populations made vulnerable by race and
limited English language capacity
Health Disparities
RACE
• Not biologic construct reflecting innate
differences
• IS a social construct capturing the social
classification of people in our raceconscious society
• Race-associated differences in health
outcomes may in fact be due to the impacts
of racism
AFRICAN AMERICAN CITIZENSHIP STATUS & HEALTH EXPERIENCE
FROM 1619 TO 2001
TIME
SPAN
CITIZENSHIP
STATUS -YRS
PERCENT U.S.
EXPERIENCE
STATUS
16191865
246
64.40%
Chattel
slavery
18651965
100
26.18%
Virtually no
citizenship
rights
19652001
36
9.42%
Most
citizenship
rights
16192001
382
100.00%
The struggle
continues
HEALTH & HEALTH
SYSTEM EXPERIENCE
Disparate/inequitable
treatment poor health status &
outcomes. “Slave health
deficit” & “Slave health subsystem” in effect
Absent or inferior treatment
and facilities. De jure
segregation/ discrimination in
South, de facto throughout
most of health system. “Slave
health deficit” uncorrected
So. med school desegregation
1948. Imhotep Hospital
Integration Conf 1957-1964,
hospital desegregation in
federal courts 1964. Disparate
health status, outcomes, and
services with apartheid,
discrimination, institutional
racism and bias in effect.
HEALTH DISPARITIES/
INEQUITIES
Source: Byrd, WM, Clayton, LA. An American Health Dilemma, Volume 1, A Medical History of African
Americans and the Problem of Race: Beginnings to 1900, New York, NY: Routledge. 2000.
What are health disparities
Differences in health that exist among specific
populations in the:
• Incidence
• Prevalence
• Mortality
• Burden of disease
HP 2000
• Blacks: ~50% poor or near poor which
is 2X rate white of poverty
– Represents >2/3 of Black children
• Life expectancy: almost 7 years less
than the average life expectancy for
Whites.
• AIDS: leading cause of death for Blacks
aged 25-44 and >60 percent of new
AIDS cases occur among minorities; 40
are Blacks.
HP 2000 report African American
T o tal
C oronary
deaths/100 K
B lack
105
140
D M /100K
40
76
E S R D /10 00
4 .1
5 .5
fo r > 6 5
im m u n ization
P n eu m o co ccal
34
23
Influ en za
58
40
Healthy People 2010
• Increase the quality and years of
healthy life
• Eliminate health disparities
Racial/Ethnic Disparities in
Health Care
Within Medicare:
Differential utilization based on race for:
• Mammography (Gornick et al.)
• Amputations (Gornick et al.)
• Influenza vaccination (Gornick et al.)
• Lung Ca surgery (Bach et al.)
• Renal transplantation (Ayanian et al.)
• Cardiac catheterization & angioplasty (Harris et al, Ayanian et al.)
• Coronary artery bypass graft (Peterson et al.)
• Treatment of chest pain (Johnson et al.)
• Referral to cardiology specialist care (Schulman et al.)
• Pain management (Todd et al.)
Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care; IOM,
2002
Racial and ethnic disparities in health:
• Exist within a broader context where
discrimination is experienced
• Persist when insurance status, age, income
and severity of conditions are comparable
• Are not explained by patient refusal to
treatment
Unequal Treatment, continued
• Result from bias, prejudice, stereotyping
and clinical encounter uncertainty on the
part of the provider
• Result because of the complex and
fragmented nature of health care delivery
•
•
•
•
•
•
•
RECOMMENDATIONS
public education campaign
target providers: awareness, knowledge and
skills
address regulatory and policy development
develop health systems intervention: access
develop cross-cultural education
improve data collection and monitoring
increase research
“ [R ] a cia l a n d eth n ic m in o rities ten d to receive lo w er q u a lity h ea lth ca re th a n w h ites d o , even w h en
in su ra n ce sta tu s, in co m e, a g e a n d severity o f
co n d itio n s a re co m p a ra b le .” B ia s, th e rep o rt
co n clu d es, fu n ctio n s a s a m a jo r b a rrier to th e
p ro visio n o f eq u a l ca re.
U nequal T reatm ent: C onfronting R acial and E thnic D isparities in H ealth C are; Institute of M edicine, 2002
“I have a dream that my four little
children will one day live in a nation
where they will not be judged by the
color of their skin but by the content of
their character…”
Martin Luther King Jr. “I Have a Dream” address
delivered at the March on Washington for Jobs and
Freedom, August 28, 1963
Racism
• Institutional: regulations, barriers, etc.-necessary to identify to ensure access
• Personally- mediated: bias; stereotyping,
discrimination, prejudice--necessary to
identify to develop provider training
• Internalized: individual adopts/believes
stereotype--necessary to debunk myths and
develop appropriate patient materials
– Camara Jones, MD, PhD at the CDC
Summary
• There is a significant body of evidence that
has identified disparities in health care
• Recommendations of the IOM have
implications for changes in institutions and
practice within healthcare settings
• To eliminate disparities, partnerships and
more comprehensive policy approaches will
be required
Massachusetts Disparities
Race and Hispanic Ethnicity
Total
White
Black
AI/AN
Asian/PI
No race/more
than one
Hispanic (all
races)
1990
6,101,425
5,405,374
300,130
12,241
143,392
2000
6,349,097
5,367,286
343,454
15,015
240,613
382,729
287,549
428,729
Percent of Persons Living Under Federal
Poverty Level
Race*/ Hispanic Ethnicity, MA:1999
50%
Percentage
40%
30%
30%
21%
16%
20%
10%
9%
7%
0%
White
Black
Asian/PI
Hispanic
Source: U.S. Bureau of the Census, 2000 SF3 Sample Data.
* Race Alone
MA
Educational Attainment
(Less than High School)
by Race*/Hispanic Ethnicity, MA:2000
50%
43%
Percentage
40%
30%
20%
24%
24%
15%
13%
10%
0%
White
Black
Asian/PI
Hispanic
Source: U.S. Bureau of the Census, 2000 SF3 Sample Data.
* Race Alone
MA
Persons with NO
Health Care Coverage
Adults aged 18+ years, MA: 2000
25%
22%
Percentage
20%
16%
15%
10%
13%
8%
6%
5%
0%
White,
Black,
Hispanic
Asian,
non
non-
non-
Hispanic
Hispanic
Hispanic
HP2010
0%
Source: Massachusetts Department of Public Health, BRFSS.
Health care coverage: Responded “no” to the question “Do you have any kind of health care plan”.
MA
Deaths per 100,000 population
All cause Mortality
Age-Adjusted Death Rates
by Race/ Hispanic Ethnicity, MA: 2000
1,200
1,000
992.4
816.5
816.2
800
596.0
600
418.5
400
200
0
White Non- Black NonHispanic
Hispanic
Asian/PI
Hispanic
Age-adjusted to the 2000 US standard population.
Source: Massachusetts Department of Public Health, Death certificates.
MA
Discharges per 100,000 population
Age-Adjusted Rate of Hospital
Discharges for Hypertension
by Race/ Hispanic Ethnicity, MA: 1999
125
140
120
100
80
46
60
40
45
26
20
20
0
White
Black Non-
Non-
Hispanic
Hispanic
Asian/PI
Hispanic
Age-adjusted to the 2000 US standard population.
Source: Division of Health Care Finance and Policy’s Hospital Discharge Data.
MA
Deaths per 100,000 population
Age-Adjusted Death Rates for HIV/AIDS
by Race/ Hispanic Ethnicity, MA: 2000
25
19.5
20
17.7
15
10
5
1.9
**
0
White
Black Non-
Non-
Hispanic
Hispanic
Asian/PI
Hispanic
Age-adjusted to the 2000 US standard population.
Source: Massachusetts Department of Public Health, Death certificates.
** Insufficient numbers
HP2010
0.7 deaths/
100,000
3.5
MA
Minority Perinatal Health
Reports: Populations
Asian
Hispanic
Black
Chinese
Puerto Rican
Cape Verdean
Vietnamese
Dominican
Haitian
Laotian
Mexican
Jamaican
Thai
Cuban
Barbadian
Other West
Asian Indian
Colombian
Indian/Caribbean
Korean
Salvadoran
African American
Filipino
Other Central American
Nigerian
Japanese
Other South American
Other African
Pakistani
Other Hispanic
Cambodian
Percentage of Preterm* Births
by Race/ Hispanic Ethnicity,
MA: 2000
25%
Percentage
20%
12.7%
15%
10%
7.8%
7.4%
8.6%
8.3%
Hispanic
MA
5%
0%
White
Black
Asian/PI
Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation
*Preterm = gestational age less than 37 weeks
Percentage of Preterm* Births
among Black Infants by Ethnicity,
MA: 1997-2000
Percentage
25%
20%
15%
10%
7.1%
11.3% 11.5%
10.4%
10.2%
9.8%
12.7% 12.9% 13.6%
5%
ig
er
ia
n
Ja
W
m
es
ai
t
ca
In
n
di
an
/C
a.
..
BL
A
CK
A
fr
,
N
ic
an
H
-A
m
er
ic
an
Ba
rb
ad
ia
n
N
ai
ti
an
H
A
fr
ic
an
th
er
O
Ca
pe
Ve
rd
ea
n
0%
Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation
*Preterm = gestational age less than 37 weeks
Percentage
Adequate Prenatal Care* by Race and
Hispanic Ethnicity, MA: 2000
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
83%
White
66%
67%
Black
Hispanic
72%
Asian/PI
79%
MA
Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation
*Adequate prenatal care is a measure of the timing and number of prenatal care visits. Based on
Kessner Index.
65% 67% 67%
st
an
i
A
SI
A
N
Fi
l ip
A
in
si
an
o
In
di
an
Ch
in
es
e
Ko
re
an
Ja
pa
ne
se
ai
Pa
ki
Ca
m
77% 79% 80% 80%
76%
72%
45% 48%
Th
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
bo
di
an
La
ot
Vi
ia
n
et
na
m
es
e
Percentage
Adequate Prenatal Care* among Asian
Mothers by Ethnicity,
MA: 1996-1997
Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation
*Adequate prenatal care is a measure of the timing and number of prenatal care visits. Based on
Kessner Index.
Percentage
Non-English Language Preference by
Race and Hispanic Ethnicity,
MA: 2000
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
47%
35%
12%
10%
3%
White
Black
Hispanic
Asian/PI
MA
Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation
82%
61%
29%
34%
41%
45%
67%
68%
47%
14%
Pu
er
to
Ri
ca
O
n
th
er
O
S.
th
A
er
.
H
is
pa
ni
H
c
IS
PA
N
IC
M
ex
ic
an
Co
lo
m
bi
an
Do
m
in
ic
an
O
th
er
C.
A
Sa
.
lv
ad
or
an
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Cu
ba
n
Percentage
Spanish Language Preference among
Hispanic Mothers by Ethnicity, MA:
1997-2000
Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation
Office Of Minority Health
DHHS
CLAS: Culturally and
Linguistically Appropriate
Services
OMH National Standards for Cultural
and Linguistic Services
• 14 standards: inform, guide, facilitate
development of strategies
• Three themes
-Culturally competent care
-Language access services (mandated)
-Organizational support for cultural
competence
Standard 1 (CLAS definition--behavior and
communication with patients)
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
• Protocols that are known to all staff on treating patients who are
from different backgrounds are clear
• Respect for patient values and beliefs are paramount
• Clinical and administrative information must be presented
• Use patient’s language
Standard 2 (workforce diversity)
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
•
•
•
•
•
Diverse staff
Reflective of demographics
Value the journey
Assessment of needs of consumers
Proactive strategies
Standard 3 (staff training)
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
•
•
•
•
•
•
Communicates expectations
Communicate policies and procedures
Create environment for staff to be on the journey
Organization and sub-contracts and affiliates
CEU/CME
Content: working across differences, effective communication, conflict
resolution, work with interpreters, clinical differences by race
Standard 4 (Interpreter Services mandate)
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
• Ensure effective communication to LEP (OCR guidance)
• LEP: a consumer who cannot speak, read or understand
English that permits effective interaction with clinical and nonclinical staff
• Preference is face to face with: bilingual clinical staff , then
trained interpreter staff then contracted then telephonic
Standard 5 (notice of rights)
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
•
•
•
•
•
•
The right to an interpreter at no cost
Posted signage
At all points of contact
Policies and procedures
Primary educational materials
Translation of pertinent patient materials
Standard 6 (Interpreter competencies)
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)
• Assess and assure training of interpreter staff
• Interpreters must be competent in both languages-source and
target
• Interpreters must be trained in the art and ethics of interpreting
• Family and friends ought not to be encouraged (forbidden in
ERIL)
• No use of children
Standard 7 (Translated materials)
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
•
•
•
•
Effective language assistance program
Written materials that are routinely provided to English speakers
Identify language groups in area
Policies and procedures relative to translations
Standard 8 (organizational frameworks)
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
• Identify how will target and reach out to diverse populations
• Organizational values, systems, procedures identified and
points of accountability/oversight for implementation and
monitoring
Standard 9 (Performance monitoring)
Health Care Organizations Should Conduct Initial
and Ongoing Organizational Self-Assessments of
CLAS-Related Activities and Are Encouraged To
Integrate Cultural and Linguistic CompetenceRelated Measures Into Their Internal Audits,
Performance Improvement Programs, Patient
Satisfaction Assessments, and Outcomes-Based
Evaluations
•
•
•
•
•
Obtain baseline
Inventory policies, practices and procedures
Identify capacities, strengths and weaknesses
Identify culturally and linguistic measures for QA
Link to outcomes and quality efforts: survey must be appropriate
Standard 10 (Data collection
and analysis)
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
• Legal and appropriate to collect data
• Allows for identifying who uses and not uses organization
• Allows for monitoring assessment with usage: where does
outreach need to occur
• MIS ought to identify language of parent in case of minor
• Needs to be an up-front process
Standard 11 (Community language needs
assessment)
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
•
•
•
•
•
Community profile
Obtain a variety of baseline data
Variety of data sources and information
Quantitative and qualitative
Involve consumers/community
Standard 12 (Community partnerships)
Health Care Organizations Should Develop
Participatory, Collaborative Partnerships With
Communities and Utilize a Variety of Formal and
Informal Mechanisms to Facilitate Community
and Patient/ Consumer Involvement in Designing
and Implementing CLAS--Related Activities
•
•
•
•
Responsive service delivery is collaborative
Service delivery, policy and program development
Formal and informal mechanisms
Reciprocity and mutuality between community and institutions
Standard 13 (Grievance policies and
procedures)
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
• Structure must allow for avenue to air complaints when patients
not accommodate or feel misunderstood
• Vulnerable populations
• Information on right to file a grievance
• Ombudsman or intermediary (Patient advocates)
Standard 14 (“report card”)
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
• Informing about progress
• Develop own report card
Interpreter Services
Definitions
• Interpretation: changing orally what
someone says into another language for the
listener
• Translation: changing written material from
one language into another while keeping the
same meaning
Definition: non-English speaker
• A person who cannot speak or understand
• OR has difficulty speaking or understanding
English
• Because uses a spoken language other than
English
Research Language Barriers and
Access
Extensive bibliography: Jane Perkins,
National Health Law Program: Ensuring
Linguistic Access in Health Care Settings:
An overview of Current Legal Rights and
Responsibilities found at:
http://www.kff.org/content/2003/20030821/
Language Access
• Latino pediatric access to care increased
with parent ability to speak English
• NES women cited inadequacy of translated
materials as a factor in a decision to not
obtain mammography (screen translated as
fat)
• Communication difficulty between patient
and provider
• A major reason cited by NES patients for
their dissatisfaction with care
Why are interpreter services important?
Census 2000: Massachusetts
Fastest growing communities
– Latino by 49% (US 58%)
– Asian-Americans by 66%
Languages spoken: >140 (US >300)
Language other than English: 18.2 % (US 17%)
Language proficiency :7% speak English less
than very well (US 8%)
Why are interpreter services important?
Workforce Issues
– DMA identified language differences between
providers and patients as primary barrier to
delivering competent and effective services
– Health care workers tend to be stable
– Current workforce lacks language capacity
– Poor graduation rates
– Graduates not entering health fields
Laws/regulations
• Title VI Civil Rights Law 1964 (ensure
language access)
• Voting Rights Act 1965 (bans English only
elections)
• Food Stamp Act 1977 (written and oral
assistance)
• Older Americans Act (outreach)
• Substance Abuse and Mental Health
Administration Reorganization Act(services)
• Executive Order 13166: Improving Access to
Services for Persons with Limited English
Proficiency
Laws/regulations
• Equal Educational Opportunities Act
(accommodate language differences impede
learning)
• Disadvantaged Minority Health
Improvement Act (OMH to enter into contracts
•
•
•
•
which increase LEP access)
HCFA (CMS) regulations require evaluations to be
in the language of the patient
CA: requires adequate communication methods
NJ: communication must be patient language for
substance abuse
MA : ERIL: interpreters in ED settings
DOJ/DHHS Guidance:Language access
must be provided: www.lep.gov
Four factor analysis
• Number or proportion of LEP persons
served or encountered (lang assessment)
• Frequency of contact with the program by
LEP
• Nature and importance of program to LEP
• Resources available and cost considerations
Guidance: One size does not fit all
• Interpreter services is an evolving profession
– Standards are evolving and limited # of
interpreters
• Hospitals have differing needs, resources,
patient populations and community resources
– Urban/rural
– Multiple languages differ by region
– Community composition
• Many hospitals initiated interpreter services in
response to federal guidance and requirements
Massachusetts Hospital Based
Interpreter Services
Massachusetts
• ERIL: Emergency Room Interpreters Law, 2000
• Massachusetts: Determination of Need requirements
– 52 hospitals
– Developed IS as a condition of the DoN
• MMIA’s Standards of Practice nationally recognized
– Collaborating with other national groups
– California Health Interpreters Association
– Washington state
ERIL requires provision of
competent interpreter services
• In acute care hospitals
• For all emergency room services
• To non-English speaking persons seeking
ED care or treatment
• As a condition for licensing
Definitions
Competent interpreter services are performed by
a person who is:
- Fluent in English
- Fluent in the patient’s language
- Trained and proficient in the skill and
ethics of interpreting
- Knows the specialized terms and concepts
used in medical care
Linguistic Competence: Ensuring trained
interpreter improves clinical quality
• Bear down: push down, carry a weight,
bend down, sit down, beard, chin
• Bladder: liver, vagina
• Seizures: kidnapping, cramps, stitches, lose
consciousness
• Lack vocabulary: Hmong
The Hmong language has no word
for cancer, or even the concept of
the disease. “We’re going to put a
fire in you” is the how an
inexperienced interpreter radiation
treatment to the patient, who refused
treatment.
Anne, Morse. Language Access: Helping Non-English
Speakers Navigate Health and Human Services, National
Conference of State Legislatures, 2003
Delivery System Design
• Coordination and Administration
• Scheduling and tracking
• Models of Oral assistance
–
–
–
–
–
staff
contract
employee language banks
community language banks
telephonic and remote simultaneous
• Guidelines for translation: common written
patient materials
Translation: Use trained translator
English to be translated
Rheumatoid arthritis can be acute or
chronic. Acute rheumatoid arthritis is more
common during adolescence. The cause is
believed to be due to an over-sensitive
reaction of the joints to the Beta Hemoylic
Streptococcous. The most common sites of
infection are the throat and tonsil.
Translation continued
English to Chinese to English
Wet Wind Style Joint inflammation has fast
and slow type. The fast type sees more at
small year type. The reason for its up
believes to be the joint’s over-sensitive
reaction to the blood-dissolving chain-ball
bacteria. And the affecting path is most
frequently the swallow tube and the flactpeach gland.
Source: Harvard Pilgrim HealthCare, Shani Dowd, June 2002
Key Issues
•
•
•
•
•
•
•
Policies and procedures
Identification of a coordinator
Notices and signage
Access
Training, education and qualifications
Patient records
Translated materials
Structural elements
Written policies and procedures
• Available to staff
• Identify timeliness of access
• Identify circumstances for use of telephonic
services
• Monitor and assure quality
Structural elements continued
• Annual needs assessment
• Coordinator identified to:
-Conduct the annual needs assessment
-Develop written policies and procedures
specific to the ED
-Assess interpreter skill
-Develop institutional training
-Ensure timely early identification of patient’s
needing an interpreter
Structural elements continued
• Coordinator (Con’t)
-Develop ongoing, documented quality
assurance program as part of hospital QA
-Develop and publicize grievance procedures
for problems with access
Structural Elements
Monitoring and Evaluation
• Users: patients, staff and providers and
interpreters
• User satisfaction surveys including the nonEnglish speaker
• Process indicators: Is the system working in a
way that everyone understands
• Quality indicators: Are IS meeting user needs?
• Outcome indicators: Are IS making a
difference?
Risk Reduction
• Documentation in the medical record
– Patient language preference
– Interpreter’s name
– Declination of service: reason and interpreter
• Provide timely and uniform communication
• Ensure systematic data collection
– access to IS to correct language and race fields
– utilize this data for assessment
Summary Hospital Based IS
Hospital based interpreter services programs are
most effective when
• Structured rather than ad hoc
• Comprehensive policies and procedures are
developed
• A community needs assessment and an internal
resource assessment
• Initial and ongoing training is offered
• Competency protocols are established
Closing comments
• Perception: societal and experiential
• Theories and research often fail to include
racial, ethnic and linguistic minority
subjects and have limited applicability
• Lack of inclusion in research has rendered
them invisible and assumed knowledge has
driven the process of healthcare delivery
• Vulnerable populations not monolithic
Immigrant--multiple ethnicities, different
immigrant experience
• Minority groups--multiple ethnicities
Summary
• Experiencing the health system may be
negative
– disrespect
– lack of language access
– experience of health disparities
• Acknowledging our limited understanding
is critical
• Asking about their experience is critical
• Involving community consumers critical to
the development of effective patient safety
strategies
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