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One Size Does Not Fit All:
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Meeting the Health Care
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Needs of Diverse Populations
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Amy Wilson-Stronks, Karen K. Lee, Christina L. Cordero,
April L. Kopp, and Erica Galvez
Table of Contents

Staff and Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Technical Advisory Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Chapter 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Chapter 2 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Chapter 3 A Framework for Establishing Practices to Meet the Needs of Diverse Populations . . .14

Chapter 4 Building a Foundation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Chapter 5 Collecting and Using Data to Improve Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Chapter 6 Accommodating the Needs of Specific Populations . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Chapter 7 Establishing Internal and External Collaborations . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Chapter 8 Tailoring Initiatives to Meet the Needs of Diverse Populations: A Self-Assessment Tool . . .45

Appendix A Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Appendix B Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Support for the Hospitals, Language, and Culture study is provided by a grant
from The California Endowment.
 STAFF and ACKNOWLEDGEMENTS
Hospitals, Language, and Culture
Project Staff
Amy Wilson-Stronks, MPP, CPHQ, Principal Investigator
Christina L. Cordero, PhD, MPH, Senior Research Associate
Karen K. Lee, MS, Senior Research Associate
Isa Rodriguez, Senior Secretary
April L. Kopp, MFA, Consultant
Research Advisors
Maureen Carr, MBA, Project Director, The Joint Commission
Shelby Dunster, BA, Director, The Joint Commission
Erica Galvez, MA, Associate Project Director, The Joint Commission

Acknowledgements
Project Advisors Participating Hospitals
Felicia Batts, MPH We would like to give special thanks to the 60 hospitals
Romana Hasnain-Wynia, PhD that participated in this study and the hospital liaisons
Elizabeth Jacobs, MD, MPP who coordinated all of the activities related to the site
Sunita Mutha, MD, FACP visits. As agreed at the commencement of this study, we
are not releasing the names of these hospitals, but we
Reviewers
wish to acknowledge them for their efforts to further the
We would like to acknowledge the many individuals
understanding of providing culturally competent care.
who provided thoughtful review of this report: Wilma
Alvarado-Little, Dennis P. Andrulis, Felicia Batts, Special Thanks
Ignatius Bau, Barbara Braun, Maureen Carr, Lynn Fors, We would like to acknowledge Paul M. Schyve, Senior Vice
Louis C. Hampers, Romana Hasnain-Wynia, Frederick President; Robert A. Wise, Vice President, Division of
Hobby, Elizabeth Jacobs, Robert C. Like, Edward L. Standards and Survey Methods; and Amy Panagopoulos,
Martinez, Jennifer Matiasek, Luben Montoya, Jason Director, Division of Standards and Survey Methods, at The
Ormsby, Yolanda Partida, Cynthia Roat, Mark Joint Commission for their guidance and encouragement.
Rukavina, Karin Ruschke, Gayle Tang, Sue Wintz, and
We would also like to thank Ignatius Bau, Director
Mara K. Youdelman.
of Culturally Competent Health Systems at The
Editorial Support California Endowment, for his continued support.
Many thanks for the editorial support of Johanna Without his vision, we would not have been able to con-
Rosenbohm. duct this study.
Graphic Design
Bill Bullerman

Suggested Citation
Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One Size Does Not Fit All: Meeting The Health Care

4
Needs of Diverse Populations. Oakbrook Terrace, IL: The Joint Commission; 2008.
© 2008 by The Joint Commission. All rights reserved. This report is available for download on The Joint
Commission’s website at www.jointcommission.org/PatientSafety/HLC/.
Permission to reproduce this report for noncommercial, educational purposes with display of attribution is
granted. For other requests regarding permission to reprint, please call (630) 792-5954.
TECHNICAL ADVISORY PANEL
Dennis P. Andrulis, PhD, MPH Lindsay K. Mann, FACHE
Center for Health Equality, Drexel University Kaweah Delta Health Care District
School of Public Health
Edward L. Martinez, MS
Felicia A. Batts, MPH Health Management Consultant
Consulting By Design
Sunita Mutha, MD, FACP
Ignatius Bau, JD University of California – San Francisco
The California Endowment
Guadalupe Pacheco, MSW
Mary Lou Bond, PhD, RN Office of Minority Health, U.S. Department
University of Texas at Arlington of Health and Human Services

Samuel S. Fager, MD, MBA, JD Yolanda Partida, MSW, DPA

Independent Consultant Hablamos Juntos

Heng Lam Foong Mark Rukavina, MBA

The Trust for Public Land, Healthy Parks, The Access Project
Health Communities
Karin Ruschke, MA
Alexander R. Green, MD, MPH International Language Services, Inc.
The Disparities Solutions Center,
Massachusetts General Hospital Susan C. Scrimshaw, PhD
Simmons College
Louis C. Hampers, MD, MBA, FAAP
The Children’s Hospital of Denver Craig Spivey, MSW
Project Brotherhood
Romana Hasnain-Wynia, PhD
Center for Healthcare Equity, Feinberg School Gayle Tang, MSN, RN
of Medicine, Northwestern University Kaiser Permanente

Sandral Hullett, MD, MPH Mara K. Youdelman, JD, LLM

Cooper Green Hospital National Health Law Program

Elizabeth A. Jacobs, MD, MPP

The John H. Stroger Jr. Hospital of Cook County,
Rush University Medical Center

5
 ABOUT THE AUTHORS
Amy Wilson-Stronks, MPP, CPHQ
Amy is the project director for health disparities work in the Division of Standards and Survey Methods at The
Joint Commission and is the principal investigator of the Hospitals, Language, and Culture (HLC) study. She is
directing the work of The Joint Commission to assess and evaluate accreditation standards related to culturally and
linguistically appropriate services, and is developing a comprehensive training program on these issues for Joint
Commission surveyors. She also serves on a number of national advisory committees on subjects related to cultural
competence and patient-centered care. Amy earned a master of public policy degree in health policy and a gradu-
ate certificate in health administration and policy from the University of Chicago, and she is a Certified Professional
in Healthcare Quality (CPHQ).

Karen K. Lee, MS
Karen is a senior research associate in the Division of Standards and Survey Methods at The Joint Commission, work-
ing on research, training, and dissemination activities for the HLC study. Before joining The Joint Commission, she
developed consumer-oriented multimedia educational materials on various health topics with State of the Art, Inc.,
and explored issues of health communication and health disparities at the Dana Farber Cancer Institute. Karen earned
her master of science in public health from Harvard University.

Christina L. Cordero, PhD, MPH

Tina is a senior research associate in the Division of Standards and Survey Methods at The Joint Commission, work-
ing on the HLC study and providing research and technical support for ongoing projects and training activities.
Previously, she conducted basic science and public health research at Northwestern University’s Feinberg School of
Medicine, elucidating the role of the Vibrio cholerae RTX toxin in cholera disease. Tina earned both her doctor of
philosophy in immunology and microbial pathogenesis and her master of public health degrees from Northwestern
University.

April L. Kopp, MA, MFA

April is a consultant for the HLC study. She earned her master of arts degree in clinical social work at the University
of Chicago, and she earned a master of fine arts degree in writing from the University of Iowa. She has worked for
the VA Information Resource Center (VIReC) at Hines VA Hospital as well as the University Hygienic Laboratory
of Iowa, and she formerly codirected a nonprofit organization, The Patient Voice Project, with Austin Bunn. She is
a coeditor of Advocates’ Forum, a graduate social work journal of the University of Chicago School of Social Service
Administration.

Erica Galvez, MA
Erica is an associate project director in the Center for Quality, Patient Safety, and Innovation Research at The Joint
Commission. Her current research focuses on various aspects of health care quality and safety, with a specific empha-
sis on vulnerable populations. Prior to joining The Joint Commission, she worked for the Tri-Ethnic Center for
Prevention Research and conducted public policy research in Mexico and the United Kingdom. She is the coauthor
of Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings. Erica earned her master
6 of arts degree in political science from the University of Colorado – Boulder.
EXECUTIVE SUMMARY
Racial and ethnic health disparities are linked to poorer for improving cultural competence within hospitals
health outcomes and lower quality care. Language and and/or directly meeting the C&L needs of diverse patient
cultural issues can have a significant impact on these dis- populations as reported by interview participants. These
parities when not addressed by health care organizations practices were reviewed by the HLC Technical Advisory
[1]. As the diversity of our nation continues to grow, hos- Panel. The practices were then reviewed to identify com-
pitals are encountering more patients with language and mon themes. Together, the four themes that emerged
cultural barriers [2]. The multiplicity of languages, dialects, constitute a framework that provides a systemic method
and cultures can be overwhelming to hospitals and their for hospitals to think about how they provide health care
staff. The Hospitals, Language, and Culture (HLC) study that is culturally and linguistically appropriate.
set out to better understand how the challenges associated
with cultural and language (C&L) barriers are being A Framework for Establishing
addressed at 60 hospitals across the country.1 Practices to Meet the Needs of
Diverse Populations
The goal of this report is to build upon Exploring The thematic framework presented is derived from cur-
Cultural and Linguistic Services in the Nation’s Hospitals: rent practices that hospitals are employing to provide care
A Report of Findings (HLC Report of Findings) [3] to pro- and services to their diverse patient populations. As the
vide a framework for hospitals to develop and employ themes are based on practices that HLC study hospitals
practices for meeting diverse patient needs. There is no are already carrying out, organizations may find, as they
“one size fits all” solution, and the road map to organi- read this report, that they are already implementing some
zational cultural competence is unique for each hospital. of these same practices. Additionally, as hospitals likely
While this report does not provide all of the answers for face many of the same challenges and constraints in
meeting the needs of diverse patient populations, it can meeting the needs of diverse populations, there may be
help organizations overcome some of the challenges they some practices within each theme that organizations can
face when providing safe, quality health care in an establish without allocating substantial resources.
increasingly complex system. Chapter 8: Tailoring However, each individual practice is not meant to be a
Initiatives to Meet the Needs of Diverse Populations: A stand-alone solution. A range of practices spanning all
Self-Assessment Tool contains a tool that hospitals and four themes must be adopted in a systemic manner that
other health care organizations can use to promote dis- is aligned with patient needs and organizational
cussion around their current practices and guide efforts resources. While the practices identified in this report
to address the C&L needs of the populations they serve. were implemented in hospitals, many of them may be

Methodology
relevant to other health organizations.

Purposive sampling was used to select the 60 hospitals Theme 1: Building a Foundation Establishing a foun-
in this study. Data were collected during one-day site vis- dation of policies and procedures that systemically support
its at each hospital. Each site visit consisted of a series of cultural competence is a crucial component of meeting the
semi-structured interviews with CEOs, administrative needs of diverse patient populations. The role of leader-
and clinical leaders, human resources staff, and C&L ship is inherent to these types of activities — leadership
services staff such as chaplains, interpreters, and com- support is required to recognize, prioritize, and often drive
munity outreach managers. “Promising” practices were efforts that establish policies and procedures to improve
identified as those practices that appeared to be effective care and to better meet patient needs. 7

1 For more information on the Hospitals, Language, and Culture

study, including the HLC Report of Findings, please visit
www.jointcommission.org/Patient Safety/HLC.
 EXECUTIVE SUMMARY

Integrating C&L considerations into organizational pol- care and decreasing health disparities for particular popu-
icy and procedure requires a demonstration of commit- lations in the service community. Accommodations tar-
ment. Without an organizational commitment to geted to the needs of specific populations evolve as
cultural competence and subsequent action at the policy hospitals search for solutions to the challenges of providing
and procedure level, these initiatives can often be over- care to their diverse patients.
shadowed by other organizational priorities. In order to
resolve challenges such as lack of funding and resources To ensure organizations meet changing staff and patient
for C&L services, it is important for organizations to needs, the development of services and activities tailored
clarify their commitment to providing culturally com- for specific populations should be a continuous process.
petent care by creating a supportive infrastructure of While the practices outlined in this chapter show positive
policies and procedures that help staff put these ideals steps toward the delivery of culturally and linguistically
into action. appropriate care, they also indicate the complicated real-
ity of the long road ahead. Although knowledge, field
Theme 2: Collecting and Using Data to Improve experience, and technology have improved the delivery of
Services The collection and use of community- and C&L services, hospitals need to consider the balance
patient-level data is essential to developing and improv- between convenience, cost, patient safety, and quality.
ing services in health care, including services developed
to meet the needs of diverse patient populations. Theme 4: Establishing Internal and External
Instituting practices to systematically collect data allows Collaborations Collaborative practices encompass those
the effectiveness and utilization of C&L services to be that bring together multiple departments, organizations,
monitored, measured, and evaluated. This can be useful providers, and individuals to achieve objectives related
for planning so that services can be designed to meet the to culturally and linguistically appropriate care. Within
specific needs of the organization. each hospital, different stakeholders should be brought
together to develop, implement, evaluate, and improve
While many hospitals across the United States already col- initiatives aimed at meeting the needs of diverse patients.
lect community- and patient-level data, few hospitals have External collaborations can help hospitals engage their
developed systems for using them to guide service devel- community and share information and resources.
opment and improvement. A thorough understanding of
the need for C&L services, dependable information Collaboration, whether internal or external, may provide
regarding the use of those services, and the usefulness of new avenues for hospitals currently undertaking cultural
those data to improve C&L services can all contribute to competence initiatives. There is no doubt that collabo-
a hospital’s ability to identify and monitor health dispari- ration needs to play a role in all the practices outlined in
ties and provide safe, quality health care to culturally and this report. Building active relationships with cultural
linguistically diverse patients. The data collected may also brokers, traditional healers, chaplains, religious leaders,
be used to inform short- and long-term organizational and other individuals may enhance and extend the hos-
planning, help develop C&L-specific services and pro- pital’s existing C&L services. While collaborative efforts
grams, and identify limitations in staffing and resources come with their own challenges, building partnerships
that collaborative partnerships may alleviate. that bring together the champions of culturally and lin-
guistically appropriate care has the potential to move the
8
Theme 3: Accommodating the Needs of Specific entire field forward.
Populations Accommodating the needs of specific popu-
lations includes practices aimed at providing safe, quality
EXECUTIVE SUMMARY

Tailoring Initiatives to Meet the

Needs of Diverse Populations:
A Self-Assessment Tool

The self-assessment tool can be used to engage members

of the organization in discussions about the needs,
resources, and goals for providing the highest quality care
to every patient served. The tool is intended to address
the main issues that emerged from the HLC study, and
the questions are designed to promote discussion around
an organization’s need to improve or expand current
C&L services.

The authors hope that this report will be a useful guide

for hospitals and other health care organizations to develop
and improve practices that address the needs of diverse
patients. The framework presented in this report can help
organizations assess their current practices and take action
to provide high quality care to the populations they serve
in order to achieve optimal patient outcomes.

9
 CHAPTER 1: Introduction
Racial and ethnic health disparities reflect poorer health these ideas into action. However, each individual practice
outcomes and lower quality care. Language and cultural is not meant to be a stand-alone solution. A range of
issues can have a significant impact on these disparities practices spanning all four themes must be adopted in a
when not addressed by health care organizations [1]. As systemic manner that is aligned with the needs of
the diversity of our nation continues to grow, hospitals are patients and the resources of the organization.
encountering more patients with cultural and language
(C&L) barriers [2]. The multiplicity of languages, dialects, Why Is It Important to Meet the Needs
and cultures can be overwhelming to hospitals and their of Diverse Patients?
staff. The Hospitals, Language, and Culture (HLC) study It is well recognized that communication is essential to
set out to better understand how the challenges associated quality care and patient safety. Direct communication can
with C&L barriers are addressed at 60 hospitals across the be inhibited by primary language barriers, hearing or vision
country. The findings demonstrate that there is much impairment, literacy, culture, cognitive limitation, intuba-
work to be done to address C&L barriers, particularly in tion, or disease. Individuals whose care is inhibited due to
the areas of language access services, informed consent and a communication barrier or a lack of sensitivity to a cul-
related patient education processes, and the collection and tural belief may be at risk for poor outcomes [6, 7]. Data
use of patient demographic data [3]. reported to The Joint Commission demonstrate that com-
munication is the most common underlying root cause of
The health care environment of today presents many sentinel events [8]. In addition, a study conducted by
challenges — for health care organizations, individual Woolf et al. (2004) determined that miscommunication
practitioners, patients, and families. Health care organi- plays an important role in medicine [9].
zations are challenged to meet legal, regulatory, and
accreditation standards, improve health care outcomes The financial benefit of providing C&L services is diffi-
and safety among their patients, and respect bottom cult to measure. Previous studies have attempted to quan-
lines. Individual practitioners are challenged by time and tify financial benefit, but none have demonstrated an
financial restrictions as well as the impact these restric- undeniable return on investment [10-12]. However, if we
tions have on their ability to provide the best care to all understand and accept that effective communication is
patients. Lastly, patients and their families face challenges inextricably linked to language, culture, and health liter-
navigating the complex health care system, asking the acy, then it becomes clear that addressing these issues
right questions, and providing the right information so plays a significant role in improving quality and safety,
they can participate in their health care [4, 5]. resulting in a positive cost-benefit ratio [13].

The goal of this report is to build upon Exploring A Framework for Establishing
Practices to Meet the Needs of
Cultural and Linguistic Services in the Nation’s Hospitals:
Diverse Populations
A Report of Findings (HLC Report of Findings) to provide
a framework for developing and employing practices for
In order to decrease health disparities, hospitals need to
meeting the needs of diverse patients. This report will
take action to understand the needs of their patient pop-
outline a framework of four themes that reflect concepts
ulations and employ practices that help address those
the authors believe contribute to culturally and linguis-
needs. This report presents a framework for organizations
tically appropriate care. This framework is further dis-
to use when considering the practices they utilize to meet
10
cussed in Chapter 3: A Framework for Establishing
the diverse needs of their patients. Four themes emerged
Practices to Meet the Needs of Diverse Populations. The
from practices in the HLC data. First, we recognize the
meaning of each theme is then explored in greater depth
importance of building a foundation (chapter 4) of
in chapters 4 through 7. Themes are exemplified by prac-
organizational policies and procedures that can support
tices that illustrate how hospitals are currently putting
CHAPTER 1: Introduction

practices to reduce disparities in care. The second theme, organizations to work together to evaluate new and exist-
collecting and using data to improve services (chapter ing practices as a means of continued improvement.
5) recognizes the importance of using data to identify
needs, evaluate services, and improve care provided to One of the goals of the HLC study has been to provide
diverse patients. The third theme, accommodating the the field with information that is useful and relevant to
needs of specific populations (chapter 6), states that improve care for diverse patient populations. This report
organizations will need to target efforts to meet diverse accomplishes this task not only through sharing current
C&L needs. The fourth theme involves establishing ideas and practices from hospitals that participated in the
internal and external collaborations (chapter 7) to iden- HLC study, but by creating a self-assessment tool that
tify needs, share resources, and work together to meet the hospitals and other health care organizations can use to
needs of populations served. These four themes serve as help them develop, implement, evaluate, and improve
the structural backdrop for this report and for the tool in their systems for addressing the care they provide to meet
Chapter 8: Tailoring Initiatives to Meet the Needs of the needs of diverse patients. The self-assessment tool is
Diverse Populations: A Self Assessment Tool. presented in chapter 8, along with suggested uses for the
tool within organizations.
Support for Practices in this Report
The HLC study did not conduct evidence-based studies Terminology
for the practices identified in this report, but many of the The following two terms are used frequently throughout
practices reflect recommendations, guidelines, and per- this report. Additional terms are defined in the glossary
formance measures from other reports and the current lit- (appendix B).
erature. As applicable, practices are mapped to a series of
consensus-based performance expectations that support cultural competence: the ability of health care providers
effective communication from the Ethical Force Program and organizations to understand and respond effectively to
found in the American Medical Association’s report the cultural and language needs brought by the patient to
Improving Communication — Improving Care: How Health the health care encounter. Cultural competence requires
Care Organizations Can Ensure Effective, Patient-Centered organizations and their personnel to: 1) value diversity;
Communication with People from Diverse Populations [14]. 2) assess themselves; 3) manage the dynamics of difference;
In addition, practices are mapped to the federal Office of 4) acquire and institutionalize cultural knowledge; and
Minority Health’s National Standards for Culturally and 5) adapt to diversity and the cultural contexts of individu-
Linguistically Appropriate Services (CLAS) in Health Care als and communities served [17].
[15], recommendations from the HLC Report of Findings
[3], and The Joint Commission’s public policy white paper culturally and linguistically appropriate services:
“What Did the Doctor Say?:” Improving Health Literacy to health care services that are respectful of and responsive
Protect Patient Safety [16]. These supporting references are to cultural and language needs [15].
included throughout the report.

How to Use this Report

While this report does not provide all of the answers for
meeting the needs of diverse patient populations, it can
help organizations overcome some of the challenges they 11
face when providing safe, quality health care in an increas-
ingly complex system. The authors hope this report will
inspire ideas for addressing diverse needs and encourage
 CHAPTER 2: Methodology
The framework described in this report is based on infor- Administrative interviews consisted of a single-person
mation collected during interviews with individuals work- interview with each hospital CEO, and leadership, human
ing in a variety of hospitals across the country. Hospital resources, and C&L services group interviews, consisting
sampling and data collection methods are discussed in of three hospital staff members from each area. Participants
detail in Exploring Cultural and Linguistic Services in the were engaged in dialogues about the challenges their hos-
Nation’s Hospitals: A Report of Findings (HLC Report of pitals face when providing care to culturally and linguisti-
Findings); therefore these two methodological components cally diverse patients, how they are able to overcome those
are revisited only briefly below [3]. challenges, and what they perceive to be the strengths and
weaknesses of their current systems for providing culturally
The HLC study was approved by The Joint Commission and linguistically appropriate care.
contracted institutional review board, Independent Review
Consulting, Inc., and the institutional review boards of Data Analysis
several participating hospitals. The study began with the following research question:
Are there promising practices that are helpful to and can be
Hospital Sample replicated by other hospitals? Two researchers independ-
Sixty hospitals from 32 states participated in the HLC ently identified and coded promising practices in admin-
study. Half of the participating hospitals (n = 30) were istrative interview transcripts that appeared to be effective
selected using 1990 and 2000 United States Census and for improving cultural competence within organizations
American Hospital Association data. Counties that satis- and/or directly meeting the C&L needs of diverse patient
fied specific size, language, nativity, and racial and ethnic populations as reported by interview participants.
population criteria were randomly selected; hospitals Qualitative research software NVIVO 2.0 (QSR
within selected counties were then recruited for study par- International, Victoria, Australia) was used to code and
ticipation. The other 30 hospitals were hand-selected by store transcripts. Because the HLC study was not able to
the project team to ensure that hospitals making a con- measure or validate the effectiveness of practices dis-
certed effort to address the cultural and language (C&L) cussed during interviews, the researchers developed an
needs of their patients were included in the study. These independent set of criteria to assess each coded practice.
hospitals were either self-nominated or nominated by a Coded practices had to meet at least one of the following
member of the project team or Technical Advisory Panel criteria to remain a promising practice:
(TAP) who had first-hand knowledge of their efforts. 1. The practice is reported to benefit the quality or
safety of patient care as evidenced by at least one of
Data Collection the following:
A one-day site visit was conducted at each participating • Improved patient satisfaction
hospital between September 2005 and March 2006 by • Reduction in medical errors/risks
HLC project staff and members of a trained research • Improved staff competence
team. Two individuals conducted each site visit (a trained • Improved access to language services
interviewer and a trained note-taker), one of whom was • Facilitation of the continuity of care
always a project staff member. Each site visit consisted of 2. The practice is reported to respond to a challenge or
a series of semistructured interviews with hospital admin- need in an innovative manner.
istrative staff and a separate series of interviews with floor 3. The practice is reported to improve the hospital’s mar-
12 staff that have direct patient contact on a regular basis. ket position or financial status while benefiting the
This report reflects only the information gathered during quality or safety of patient care.
hospital administrative interviews.
CHAPTER 2: Methodology

The same two researchers jointly reviewed each practice Together, these themes constitute a framework that pro-
to determine whether it sufficiently met one or more cri- vides both an overarching context for each practice, and
terion; 163 practices were identified through this process. a systemic method for hospitals to think about how they
provide health care that is culturally and linguistically
Technical Advisory Panel Survey Members of the appropriate. The four themes are discussed in detail in
project’s TAP2 completed a survey to classify each of the chapters 4 through 7. Due to space constraints and a
163 practices as promising or not promising based on desire to emphasize the thematic framework of this
the criteria used by HLC staff, in addition to their own report rather than practices alone, a subset of the 118
professional expertise. Twenty-four surveys were dissem- promising practices is presented. Only salient practices
inated; 15 completed surveys were returned. Practices that project staff members believe can be replicated in
that were identified as promising by at least 60% of most hospitals regardless of size, resources, and patient
respondents who answered each question were consid- population are discussed.
ered eligible for this report. After applying this criterion,
118 practices (72% of the original pool) were identified. Challenges and Limitations
Due to the abundance of practices initially identified as
Development of themes Based on the large number of promising, the length of the TAP survey deterred some
promising practices identified by the TAP survey, study TAP members from participating. Survey length may
personnel determined that a detailed discussion of these have also affected TAP members’ ability to thoroughly
practices was not possible and thus the original research review practices listed toward the end of the document.
question was no longer appropriate. Therefore, the As a result, practices near the end of the survey may have
research question was modified to: What common themes had a smaller likelihood of being identified as promising
exist among the practices identified as promising? The 118 by TAP members due to their placement in the survey
promising practices were subsequently assessed for com- rather than their comparative merit.
mon themes and patterns; four major themes emerged
from this analysis. Additionally, none of the practices described in this report
were measured, tested, or validated by HLC project staff.
Inclusion of a practice in this report does not imply, nor
Major Themes from the Framework is it intended to imply, that there is inferential, empirical
for Establishing Practices to Meet evidence of its effectiveness.
the Needs of Diverse Populations:
1. Building a foundation
2. Collecting and using data to improve
services
3. Accommodating the needs of specific
populations
4. Establishing internal and external
collaborations

13

2 The TAP consists of professionals from the health care field with
expertise in language and culture. A list of TAP members can be
found on page 5.
 CHAPTER 3: A Framework for Establishing Practices
to Meet the Needs of Diverse Populations
Exploring Cultural and Linguistic Services in the Nation’s Building a Foundation
Hospitals: A Report of Findings (HLC Report of Findings) Organizational policies and procedures can provide a sup-
presented a research framework consisting of six portive base for meeting the needs of diverse populations.
domains: leadership, quality improvement and data use, Establishing a foundation of policies and procedures that
workforce, provision of care and patient safety, language systemically support efforts to meet the diverse needs of
services, and community engagement. The research patients can help elevate the priority of these issues within
framework was based upon recommendations and exist- the organization, drive additional efforts, and draw support
ing frameworks from the literature for providing culturally from staff. The role of leadership is inherent to these types
and linguistically appropriate care and was used to of activities — leadership support is required to recognize,
develop the research protocol and interview questions for prioritize, and often drive efforts that establish policies and
the HLC study. procedures for improving care to better meet patient needs.

The current report presents a framework for establishing Hospitals are developing supportive infrastructures for
practices to meet the needs of diverse populations. As this cultural competence by incorporating cultural and lan-
framework is based upon data collected from the HLC guage (C&L) considerations into mission, vision, and
study, it is inherently related to the research framework. value statements; organizational planning; and hospital-
While it addresses many of the same issues as the research wide policies. These high-level initiatives are supported
framework, the framework presented here provides a new by assigning responsibility for C&L initiatives and infus-
perspective. ing cultural competence into organizational systems such
as recruitment processes and budget systems. C&L con-
This thematic framework was derived from the current prac- siderations are included in patient care through processes
tices that hospitals are employing to provide care and serv- for tracking patient needs, providing staff with the tools
ices to diverse patient populations.3 In comparison to to address these needs appropriately, developing processes
existing frameworks in the literature — which are often for incorporating interpreters into the continuum of care,
developed to reach the ideals of culturally and linguistically and developing systems for providing written materials in
appropriate care — the framework in this report is based understandable formats. Integration of C&L issues into
upon practices that hospitals are currently implementing. organizational policy and procedure requires a demon-
As each of the following themes is based upon current prac- stration of commitment. Without an organizational com-
tices, organizations may find that they are already imple- mitment to cultural competence and subsequent action at
menting some of the practices discussed within these the policy and procedural level, these initiatives can often
themes. Additionally, as hospitals likely face many of the be overshadowed by other organizational priorities.
same challenges and constraints in meeting the needs of
diverse populations, there may be some practices within Collecting and Using Data to
each theme that organizations can establish without allo- Improve Services
cating substantial resources. To help engage members of The collection and use of community- and patient-level
health care organizations in discussions about the needs, data is essential to developing and improving services in
resources, and goals for providing safe, quality care, chap- health care, including services developed to meet the needs
ter 8 presents a series of self-assessment questions organized of diverse patient populations. Hospitals are collecting and
14 by the same four themes. reviewing data to assess community and patient needs,
monitor the use of C&L services, identify areas for expan-
3 The methods for developing the HLC research framework are outlined sion or improvement of services, and identify any dispari-
in chapter 3 of the HLC Report of Findings; the process for developing
the thematic framework presented in this report can be found in ties in patient care. Instituting practices to systematically
Chapter 2: Methodology. collect data allows the effectiveness and utilization of C&L
CHAPTER 3: A Framework for Establishing Practices to Meet the Needs of
Diverse Populations

services to be monitored, measured, and evaluated. This Some centralized programs have also emerged as a means
can be useful for planning so that services can be designed of addressing the specific needs of populations that may
to meet the specific needs of the organization. consist of a significant percentage of patients. These types
of programs have been created largely in response to
It is important to collect and review demographic data to diverse cultural and religious needs. Accommodations
assess both community and patient needs before deter- targeted to the needs of specific populations evolve as
mining which C&L services are most appropriate to hospitals search for solutions to the challenges of pro-
implement. Additionally, it is critical to track how often viding care to their diverse patient populations. To ensure
these services are used to better evaluate an organization’s that organizations continue to meet staff and patient
current C&L services. Some of the services that may be needs, the development of services and activities tailored
monitored include language services, religious and spir- for specific populations should be a continuous process.
itual care services, and special dietary requests that are
cultural in nature. To support C&L services, data col- Establishing Internal and External
lected before, during, and after provision can be used to Collaborations
identify areas for service improvement or expansion. Developing partnerships within hospitals and with exter-
While many hospitals across the United States already nal organizations can provide a means for undertaking
collect such data, few hospitals have developed systems practices within the other themes. Hospitals are bring-
for using their demographic data to guide service devel- ing together diverse stakeholders, collaborating with
opment and improvement. Analyzing data from different other organizations to share information and resources,
sources and stratifying data by various factors can help and pooling existing resources with other organizations
organizations strengthen their C&L services and address to implement C&L initiatives by creating new materials
disparities in care for diverse patients. and services. Within each hospital, different stakeholders
should be brought together to develop, implement, eval-
Accommodating the Needs of uate, and improve initiatives aimed at meeting the needs
Specific Populations of diverse patients.
Culturally competent initiatives targeted to specific pop-
ulations can help reduce disparities in service provision External collaborations with other hospitals or health care
and care. Hospitals are developing practices to meet the organizations can help hospitals better address challenges
language, cultural, and health literacy challenges of spe- such as limited resources and high costs for developing
cific populations within their service community. As part new materials and programs. Hospitals are also making
of these initiatives, hospitals are integrating the concept use of community resources to help recruit and train a
of culturally competent care into staff training and edu- more diverse workforce, bridge cultural or religious barri-
cation. Hospitals are providing staff with training that ers, and raise patient awareness of hospital services and
encompasses a range of activities from self-study educa- available public programs related to the continuum of care.
tional materials to interactive group learning sessions. To Resources and programs that may benefit from collabora-
create an environment that is inclusive of all patients, tion include staff training in cultural competence, lan-
hospitals have modified or altered various aspects of their guage services, signage and written materials available in
physical space, programs, and services. Other ways hos- multiple languages, and resources for patients who speak
pitals are better serving diverse populations are by offer- languages not commonly encountered by the hospital. 15
ing services that allow patients to more easily navigate
the health care system and educating patients to
empower them to advocate for their own care.
 CHAPTER 4: Building a Foundation
Make the Mission Actionable
Practices that help hospitals build a foundation for meet-
Interviews with hospital staff revealed that it is
ing the needs of diverse patients include any practices
vital to operationalize guiding principles into
within an organization which are codified and set as offi-
actions or processes throughout the organiza-
cial processes, or which are a part of an organization’s gen-
tion. Members of the TAP supported this senti-
eral practices, operations, and/or culture. The role of
leadership is inherent to these types of activities — lead- ment with such comments as “This could be
ership support is required to recognize, prioritize, and promising if there were real initiatives to address
often drive efforts that establish policies and procedures this,” and “In theory, this should drive all leader-
that improve care to better meet the needs of diverse pop- ship behavior.” Hospital staff concurred with
ulations. Establishing a foundation of policies and proce- these ideas, with a CEO from a northeastern
dures that systemically support efforts to meet the diverse hospital stating, “It’s one thing to put it in a mis-
needs of patients can help elevate the priority of these sion and vision statement and plaster it on the
issues within the organization, drive additional efforts, wall and to say we serve all people in the com-
and draw support from staff. munity regardless of ethnicity or race; it’s
another thing to actually do it.” While it is an
Developing a Supportive Infrastructure important step forward for hospitals to express
for Cultural Competence their commitments to cultural competence in
their organization’s guiding principles, the mere
statement is empty without turning these words
A commitment to culturally competent care can be

into supporting actions, procedures, services,

reflected at the highest level by incorporating these ideals

and resources.
into an organization’s guiding principles, organizational
planning, and hospital-wide policies. These types of high-
level activities can help hospitals develop a cohesive message The distinction between making a statement and
turning that statement into action was quite evi-
dent in interviews with hospital staff. For exam-
about meeting the needs of diverse populations and better

ple, one CEO from a southern hospital mentioned

communicate this vision to staff, patients, and the public.4

the importance of their mission statement to the

As exemplified by hospitals in the study sample, a number

provision of cultural and language (C&L) services,

of different opportunities exist for incorporating cultural

noting, “We call it our community benefit strategy.

competence into system-wide practice.

In the early ’90s we created a new mission —

provide health and medical services to meet [the
It Starts with a Mission As a hospital’s policies, proce-

needs] of the community we serve. It is based on

dures, and overall practice are often driven by its mission,

a strategy of improving health status. . . . The

vision, or values, organizations may want to incorporate a

board pushed the hospital to really live the mis-

commitment to cultural competence in these guiding

sion/vision.” Although this particular hospital’s

principles, especially in the mission statement. Review of

mission statement does not include language

the mission statements of the 60 study hospitals revealed

referring directly to cultural competence, they

have operationalized their mission of “meet[ing]
4 Literature in the field has supported the development of an organiza-
tional infrastructure to serve as the foundation for and reinforce initia-

the needs of the community [they] serve” into

tives that help better meet the needs of diverse patient populations. As

actions that include the implementation of C&L

the CLAS standards mention, “Health care organizations should develop,

services. As this hospital exemplifies, statements

implement, and promote a written strategic plan that outlines clear goals,
policies, operational plans, and management accountability/oversight

16 of commitment to meeting the needs of diverse

mechanisms to provide culturally and linguistically appropriate services”

populations in an organization’s guiding principles

(CLAS Standard 8). In addition to having this infrastructure in place,
as the HLC Report of Findings recommends, “Hospital CEOs and

must go hand in hand with operationalizing those

other hospital leaders should make their commitment to culturally

commitments into supporting hospital practices.

and linguistically appropriate care highly visible to hospital staff and
patients” (Recommendation 1-2). Similarly, Improving Communication
— Improving Care advises that “the workforce [be] knowledgeable about
leadership commitment” (Content Area 1, Performance Expectation 6.1).
CHAPTER 4: Building a Foundation

that only one hospital, located in the west, directly refer- HLC research framework from Exploring Cultural and
enced the term cultural competence. Although other hos- Linguistic Services in the Nation’s Hospitals: A Report of
pitals did not directly mention cultural competence in Findings (HLC Report of Findings) [3], and performance
their mission statements, many had vision or value state- expectations from AMA’s Ethical Force report Improving
ments that referred to “vulnerable populations,” “under- Communication — Improving Care: How Health Care
served populations,” “diverse populations,” or “diverse Organizations Can Ensure Effective, Patient-centered
needs.” Hospitals seem to be using a variety of terms to Communication with People from Diverse Populations [14].
refer to their commitment to meeting the needs of diverse
populations. While it can be argued that a verbal com- Developing Policies for Cultural Competence Policies
mitment to serving the needs of “vulnerable” or “diverse” offer an additional vehicle to clearly communicate the
populations is not equivalent to providing “culturally com- organization’s commitment to cultural competence and
petent care,” it is important to recognize that hospitals are equitable care to staff.7 The study findings suggest that
making strides by including cultural competence issues at many staff are not aware of ways to meet the needs of
high administrative levels and mentioning them in their diverse patients and are sometimes not aware that it is
organization’s mission, vision, or values statements. part of their responsibility. Organizational policies artic-
ulate to staff the “dos” and “don’ts,” but are limited in
Making Cultural Competence a Part of Organizational their ability to provide guidance beyond that. Despite
Planning Hospitals can integrate cultural competence into these limitations, policies can help ensure that staff rec-
their organizational planning. As hospitals in the HLC ognize the importance of culturally and linguistically
study demonstrated, one way to integrate these needs into appropriate care to the organization and to patient care
organizational planning is to use the Office of Minority as well as their role in upholding those ideals.
Health’s National Standards for Culturally and
Linguistically Appropriate Services (CLAS) in Health Care
as a blueprint to guide equitable care [15].5 One TAP mem-
ber shared from personal experience, “This practice has
yielded good results for us program-wide. [We have] used
CLAS as a vehicle to achieve a national diversity agenda and
organizational mission.” While the CLAS standards are nei-
ther exhaustive nor prescriptive in how organizations should
provide culturally and linguistically appropriate care, they
“ “We don’t say [using CLAS standards to
guide planning is] the be-all, end-all. What
we are saying, however, is that consistent
with the system’s goal to provide an
equitable experience, [CLAS] is a blueprint
that helps us know what to target, what to
focus on. We wouldn’t know [otherwise].
present a starting point or a general framework, outlining
distinct areas in which hospitals should have systems or We [would] know by what people tell us
processes in place to address patient needs. about their experiences, but we wouldn’t
have a more formalized approach for
Hospitals can use other standards and frameworks from doing it if we hadn’t found the standards.”
–CEO from a
the literature to guide organizational planning. Other
resources include The Joint Commission’s standards,6 the

5 Integrating cultural competence into organizational planning is an impor-

tant step toward meeting the needs of diverse patient populations. Improving
Communication — Improving Care, for example, advises that “the organiza-
tion’s written strategic and operational plans address identifying and appro-
priately meeting the communication needs of communication-vulnerable
populations” (Content Area 1, Performance Expectation 1.0).
northeastern hospital

”
7 The role of organizational policies that support cultural competence
has been recognized in the literature. Improving Communication —
Improving Care suggests that “the organization has policies that address
17

6 The Joint Commission’s standards have been mapped to the CLAS the communication needs of communication-vulnerable populations
Standards in a document available at www.jointcommission.org/ and that place these needs in the context of other organizational needs
PatientSafety/HLC/. and priorities” (Content Area 1, Performance Expectation 4.0).
 CHAPTER 4: Building a Foundation

What is a Professional Health

Several HLC study hospitals mentioned that organizational
Care Interpreter?
policies reinforce cultural sensitivity in the provision of care.
The “interpreters” referred to within this report are
In some cases, this included punitive measures that would
considered professional, trained, and evaluated
be taken if violations occurred, such as removal of staff or
mandatory facilitation of a peer discussion group on cul- interpreters, not simply bilingual individuals. The
tural sensitivity.8 While policies may provide a definitive National Council on Interpreting in Health Care
means of addressing the needs of diverse patients, they are defines a professional health care interpreter as
not a substitute for education or a means for monitoring “an individual with appropriate training and expe-
compliance. Staff awareness and cultural competence rience who is able to interpret with consistency
and accuracy and who adheres to a code of pro-
fessional ethics” [18]. Interpreters can be on-site
should be built upon a shared desire to understand and

interpreters; interpreting services could also be

meet the needs of patients, rather than a means of avoiding

provided via telephone or video.

punishment.

In addition to general staff behavior, organizational poli-

cies can lend support for hospital procedures such as the Recruiting and Sustaining a Diverse Workforce
use of professional health care interpreters. Several of the Hospitals can prioritize diversity within recruitment and
hospitals in the study mentioned that their organizations hiring processes in order to incorporate cultural compe-
refrain from the use of family, minors, or other untrained tence considerations at the workforce level.9 Some hos-
individuals as interpreters, although staff interviews pitals reported efforts to increase the ethnic and/or
revealed that many of them face challenges when han- language concordance between their staff and patient
dling situations in which patients bring a family member population. As a human resources staff member from a
or friend and prefer this individual over the hospital-pro- midwestern hospital stated, “We advertise in local neigh-
vided interpreter. Hospital policies may play a significant borhood papers for certain positions, and participate in
role in addressing such challenges by communicating to job fairs. There is one [job fair] focused on Latinos.
staff a clear, universal procedure for navigating this type Nurse recruitment is a big issue everywhere — bilingual
of situation. Any organizational policies should be nurses get the red carpet treatment.”
accompanied by staff training (see Chapter 6:
Accommodating the Needs of Specific Populations). Once hospitals recruit a diversified staff, they must also
consider how they will maintain their workforce,10 which
Integrating Culture and Language presents its own set of challenges. A midwestern hospital
into Organizational Systems transformed its obstetrics workforce from a branch con-
Incorporating the ideals of cultural competence into sisting entirely of male doctors to a bilingual department
planning processes, guiding principles, and policies is a with more female than male physicians over the course of
strong starting point for cultural competence; the infu- seven years. This practice subsequently increased their
sion of these principles into organizational systems is the patient population. As the CEO of the hospital noted,
next logical step. For the purposes of this report, organi-
zational systems encompass processes that are at a higher 9 Practices that help organizations diversify staff through their recruitment
and hiring processes is addressed by CLAS Standard 2: “Health care
level in the organization than the direct delivery of organizations should implement strategies to recruit, retain, and promote
patient care. at all levels of the organization a diverse staff and leadership that are

18
representative of the demographic characteristics of the service area.”

8 Having specific actions tied to the violation of policies on respect or cultural 10 To help formalize processes around maintaining a diversified staff,
sensitivity is supported by Improving Communication — Improving Care, Improving Communication — Improving Care suggests that the organiza-
which recommends that “the organization has a protocol for identifying tion have “a written plan that includes goals and policies for maintain-
and responding to members of its workforce who communicate with indi- ing a workforce that meets the needs of the populations it serves —
viduals in ways that lack respect, compassion or socio-cultural sensitivity” especially its communication-vulnerable populations” (Content Area 4,
(Content Area 5a, Performance Expectation 4.0). Performance Expectations 1.0).
CHAPTER 4: Building a Foundation

“The environment is different from most other hospitals. The practice suggested here is to have a task force that
There is a hospitality focus. [This hospital’s staff ] needs to operates at a high level, which means taking responsibility
deal with patients [and] their cultural demands; therefore, for and driving initiatives around cultural competence. As
people choose this hospital for its approach to [obstetrics].” C&L service staff from a midwestern hospital said, “When
we started a small committee, we only had a core group of
Recruiting a diversified workforce does not come without dedicated people. Then, [from] 1995 to 1996, [the hospi-
challenges. A lack of resources for undertaking these types tal] decided to revise the delivery of care with managed
of recruitment efforts was cited by hospitals as one of the care [and] realized that profitability was related to provid-
major challenges they face. The competitive environment ing C&L service. The committee became more of a strate-
of recruitment can pose additional challenges for sustain- gic team. . . . No hospital can do an adequate job unless it
ing a diverse workforce. As the aforementioned CEO said, formulates a high-quality task force group. A committee
“Other hospitals are stealing the staff [we have] trained.” just can’t do it, but once we were at the system-wide task
force level, we were able to get ‘clout’.” As this example
Some hospitals are resolving the issue of sustaining a diverse shows, creating a task force that has the power to influence
workforce by providing financial incentives. A member of planning and organizational-level change is a substantial
leadership from a western hospital noted, “We have put undertaking that requires the active participation of a
waivers on some positions so that only people who are number of stakeholders from throughout the organization,
bilingual can be hired for that position. We also pay our including leadership. Involving high-level managers and
staff to interpret. It [provides] incentives [for] staff to work organizational decision makers may help move initiatives
on these skills so that they can get additional pay.” It is forward. While the hospital in this example is part of a sys-
important to keep in mind that any staff used to interpret tem, the high-level task force can be implemented in inde-
should be trained and assessed in both the target language pendent organizations. The important piece of this practice
and English. Hospitals can provide incentives for staff is assembling a group that will lead and take responsibility
members who are currently or who become professional for meeting the needs of diverse patients. This may help
interpreters. Some hospitals mentioned that they are not streamline activities and drive outcomes. Ideally, this high-
sure how to start recruiting more diverse staff. As hospitals level task force would consist of a multidisciplinary group
try to address these challenges, some have targeted ethnic of members with diverse backgrounds (see Chapter 7:
media outlets to aid their recruitment efforts. Collaboration Establishing Internal and External Collaborations).
with other entities such as community organizations or
academic institutions may provide additional resources Structuring Supportive Budget Systems for Culturally
and opportunities (see Chapter 7: Establishing Internal and and Linguistically Appropriate Care Another crucial
External Collaborations). element needed to support cultural competence within
an organization is the establishment of internal budget
Creating a High-Level Task Force Hospitals felt it was systems that support culturally and linguistically appro-
important to establish a high-level task force to drive ini- priate care.12 This is especially important given that the
tiatives and take responsibility for diversity-related issues majority of HLC study hospitals — ninety percent —
within the organization.11 While having any organiza- mentioned a lack of funding as a challenge for C&L serv-
tional committee or entity driving its diversity initiatives ices. When asked what would give C&L services the
is valuable, the committee’s recognition by hospital lead- greatest boost, respondents overwhelmingly stated “more
ership is key to its influence in effecting change within money” or “reimbursement for interpreter services.” Some 19
the hospital. of these financial challenges can be overcome through

11 Improving Communication — Improving Care states, “At least one 12 Budget systems that promote the use of language services is supported
individual or committee has as one of its charges a focus on addressing by the HLC Report of Findings: “Financial incentives should be created
the specific needs of communication-vulnerable populations” (Content to promote, develop, and maintain accessibility to qualified health care
Area 1, Performance Expectation 5.1). interpreters” (Recommendation 1-4).
 CHAPTER 4: Building a Foundation

external funding sources, including reimbursement This information may include the patient’s age, gender,
through Medicaid and State Children’s Health Insurance race/ethnicity, primary spoken and/or written language,
Program (SCHIP) programs, joint collaborations, and religion, sexual orientation, disabilities, cultural needs,
grant funding.13 dietary needs, and health literacy level. The data can serve
multiple purposes and will help inform staff of the patient’s
While these sources may address funding issues overall, communication needs throughout the health care
it is equally important to examine the internal budget encounter. Additionally, on the aggregate level, these meas-
systems, which may inadvertently create barriers. While ures may serve as one way for hospitals to track demand for
there is no ideal universal budget system for the provision language services, such as interpreters or other language
of language services, hospitals are finding different ways access services (see Chapter 5: Collecting and Using Data to
to remove such financial barriers. One midwestern hos- Improve Services). Hospitals utilized a wide range of track-
pital has centralized its budget for interpreter services so ing systems, such as the use of stickers or other flagging
that the use of interpreter services is no longer budgeted devices in the chart indicating the need for language serv-
and charged to individual departments. Although this ices; direct documentation in the patient record; a patient
was a relatively new practice at this hospital at the time summary face sheet including categories for language bar-
of the study, its results were promising. A C&L service riers, physical constraints, etc.; and color-coded armbands
staff member remarked, “[It is] amazing how [the cen- that identify the different languages spoken by a patient.
tralization] has changed the resistance to using inter-
preters.” As budget systems may create a considerable While a wide variety of tracking systems exist, the need for
disincentive to utilizing C&L services, hospitals should consistency in using these systems is paramount. One
consider how these fundamental systems may impact the member of C&L services from a midwestern hospital
services they provide. Staff should not be inhibited to use noted that although their electronic record system includes
C&L services to meet patient needs. Even if budgets for a field for recording a patient’s C&L needs, a challenge
these services are not centralized, monitoring patient they continually face is that the field is not mandatory.
needs and utilization of C&L services (see Chapter 5: Despite the fact that this hospital has made notable efforts
Collecting and Using Data to Improve Services) may to establish a process for identifying patient needs, it is
help organizations evaluate the effectiveness of their cur- unclear how effective these systems will be without consis-
rent systems or processes. tent documentation. Additionally, although the initial

Integrating Cultural Competence

into Patient Care
Changes in patient care are necessary to complement cul-
tural competence at the organizational planning and sys-
tems levels. These practices include any processes that
hospitals use to identify patients’ diverse needs, to match
these needs to appropriate services, and to effectively com-
“ “We are trying to capture
[interpretation services] in one
central budget — trying not to put
departments in the position that they
avoid calling language line because
it will come out of their budget. Now it
comes out of the Guest Services
municate with patients throughout the provision of care.
budget…we don’t want people to be
reticent because of the budget.”
Tracking Patient Needs One important component of car-
20
–A member of leadership from
ing for diverse populations is providing staff with the nec-
a midwestern hospital

”
essary tools to easily collect information on patient needs.
13 To provide health care organizations with more information on reim-
bursement models, the Access Project and the National Health Law
Program (NHeLP) released the Language Services Action Kit, available
at www.accessproject.org/adobe/language_services_action_kit.pdf.
CHAPTER 4: Building a Foundation

identification of patient needs is important, organizations Incorporating Interpreters into Patient Care As many
should keep in mind that all of a patient’s C&L needs may of the hospitals shared, interpreters can facilitate patient-
not have been captured in that first assessment. Patient provider communication throughout the continuum of
needs should subsequently be documented over time as care.15 For example, in addition to providing services dur-
they are identified in order to provide both effective hand- ing the patient-provider encounter, hospitals utilized inter-
off and patient-provider communication. preters throughout a patient’s visit, from the admission
process to explaining their rights and through the duration
Determining Appropriate Language Services As with of laboratory tests.
systems for tracking patient needs, hospitals developed a
variety of tools, including decision trees and charts to Interpreters can be used to facilitate pre-visit scheduling
help guide staff through the decision process of selecting and logistics. One northeastern hospital, for example,
appropriate language services and present information developed a partnership between their Interpreter
for accessing those services.14 These tools give hospitals Department and doctors’ offices within the area. To stream-
an additional opportunity to communicate to staff any line this process, interpreters would schedule and attend
related policies or procedures regarding C&L-specific visits with the patient as well as call before outpatient vis-
services. By clearly communicating these procedures its to ensure that patients knew where to go. Utilizing inter-
and giving decision-making tools to staff, hospitals preters to help with scheduling and logistics in this way can
can increase the likelihood that staff will access the help alleviate navigational burdens and potentially reduce
appropriate services more consistently. the number of no-shows for office visits.

These tools are meant to complement and reinforce — Translating Written Materials While the practices dis-
not replace — other communication, education, and cussed so far have primarily revolved around oral commu-
training activities. For example, one of the challenges men- nication and the use of interpreter services, C&L
tioned by hospital leadership is that staff may not be using considerations are applicable to all points of communica-
the telephone interpreter service as much as they should. tion with patients, including any printed materials.16
While staff may not be aware of this service or the appro- Examples of printed patient materials that hospitals may
priate situations in which hospital procedure dictates its need to provide in multiple languages or in plain language
use, hospitals should not overlook other factors that may include informed consent forms, educational materials,
contribute to the problem. In this case, the low rate of tele- written instructions, navigational signage, and medication
phone service use may be linked to the staff’s perception information. HLC study hospitals developed systems for
or ease of use of the telephone service, cost issues, envi- providing medication information and prescription labels
ronmental barriers, or low-quality equipment. In order to in a patient’s primary language. Hospitals may also con-
address such challenges, hospitals should communicate sider using symbols to bridge barriers presented by health
directly with staff and provide tools that streamline pro- literacy. A western hospital, for example, used symbols on
cedures. One approach in this example would be to collect medication labels to communicate instructions for taking
data on the utilization of telephone services and in-person medications to patients. Hospitals should keep in mind
interpreters as well as the costs associated with those serv-
15 Joint Commission standards require that organizations provide “inter-
ices (see Chapter 5: Collecting and Using Data to Improve pretation (including translation) services as necessary.” In addition, as
Services). These data can then be coupled with feedback recommended in the HLC Report of Findings, “Health care interpreters

21
should be used to facilitate communication during all informed consent
from staff to reconcile any C&L-specific service issues. processes involving patients with limited English proficiency, and
cultural brokers should be used as a resource when a patient’s cultural
14 Providing staff with information on accessing appropriate services beliefs impact care” (Recommendation 4-2).
is addressed by Improving Communication — Improving Care, “The
workforce knows, or has access to information outlining, the primary 16 Joint Commission standards require that “written information provided
contact person or office for interpretation services, workforce develop- is appropriate to the age, understanding, and, as appropriate to the
ment, communication training and other relevant communication population served, the language of the patient.”
issues” (Content Area 1, Performance Expectation 6.2).
 CHAPTER 4: Building a Foundation

that any written materials that are translated should be eval- Conclusions
uated in order to ensure that the intended information is Building an infrastructure by developing hospital policies
accurately conveyed. and procedures that support cultural competence is a cru-
cial component of meeting the needs of diverse patient
Hospitals are making strides in providing written materi- populations. Integrating C&L considerations into orga-
als in multiple languages. Despite these successes, hospi- nizational policy and procedure requires a demonstration
tals continue to struggle to provide materials in languages of commitment. Without an organizational commitment
they encounter less frequently. As resources are often lim- to cultural competence and subsequent action at the pol-
ited, this may be another area in which collaboration with icy and procedure level, these initiatives can often be over-
other organizations may provide supplemental resources shadowed by other organizational priorities. One of the
(see Chapter 7: Establishing Internal and External most prominent challenges identified by HLC study hos-
Collaborations). To help hospitals with these types of ini- pitals is the constant competition between C&L services
tiatives, available resources include the Agency for and other hospital priorities, which often results in a lack
Healthcare Research and Quality’s (AHRQ) report, Is Our of financial and other resources for C&L services.
Pharmacy Meeting Patients’ Needs?, which guides hospitals Another common challenge is a lack of clarity in organi-
through conducting a health literacy assessment of their zational communication to staff regarding the importance
pharmacy and patient needs [19]. of cultural competence and identifying who, ultimately, is
responsible for providing culturally competent care.

Which Written Materials Need

to be Translated?
In order to resolve these challenges, it is important for

Written information is difficult to classify as “vital” or

organizations to clarify their commitment to providing

“nonvital,” and some documents may include both

culturally competent care by creating a supportive infra-

vital and nonvital information. However, examples

structure of policies and procedures that help staff put
of vital and nonvital written materials include:
these ideals into action. The self-assessment questions
provided in chapter 8 can help hospitals and other health
Vital: Nonvital:
• Consent and • Menus
care organizations further explore the types of policies

complaint forms • Third-party docu-

• Information about ments, forms, or
free language assis- pamphlets distributed
tance programs or as a public service
services
• Notices of eligibility
criteria, rights, denial,
loss, or decreases in
benefits or services
• Intake forms that
• Large documents
such as enrollment
handbooks (although
vital information con-
tained within these
documents may need
“ “Educational materials, we always
have, at least in Spanish as far
as informed consent documents
[and] patient education materials.
Our computerized system also
has a drop-down option…some
may have important to be translated of the printed things are in the two
consequences languages.”
Source: Office for Civil Rights [20] –A member of leadership from
22
a southern hospital

”
CHAPTER 4: Building a Foundation

and/or procedures that will support their organizations in

better meeting the needs of diverse patient populations.
Other resources, such as the California Health Care
Safety Net Institute’s Straight Talk: Model Hospital Policies
and Procedures on Language Access and the Georgetown
National Center for Cultural Competence’s Cultural and

“
Linguistic Competence Policy Assessment, can provide addi-
tional guidance as hospitals work to build their support- “I think the biggest challenge
ive foundation of policies and procedures [21, 22]. 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. . . .
While these types of policies and procedures are impor-

[cultural sensitivity] does not happen

tant, they are only one of the building blocks and should

unless you invest in your employees.”

be accompanied or supported by data collection and
evaluation (chapter 5), accommodations to patient needs
–CEO from a western hospital
(chapter 6), and internal and external collaborations
(chapter 7). For example, data collection on patient
needs and community demographics is crucial to devel-
oping strategic initiatives, determining staff recruitment
targets/staff-patient concordance goals, and developing
patient-centered visits and communications. Data are
needed for continually evaluating or monitoring of the
”
effectiveness of these policies and procedures once they
are in place. Remember that while policies and proce-
dures that support cultural competence are vital to meet-
ing the needs of diverse population, they make up only
one component of the framework.

23
 CHAPTER 5: Collecting and Using Data
to Improve Services
Examples of Demographic
The collection and use of data is essential to improving

Data to Collect
health care services, including those services developed to
• Age • Primary spoken and/or
meet the needs of diverse patient populations.17
• Cultural needs* written language
Instituting practices to systematically collect data allows
• Dietary needs* • Race/ethnicity
the effectiveness and utilization of cultural and language
(C&L) services to be monitored, measured, and evalu- • Disability* • Religion
ated. These practices can be useful for planning and • Gender • Sexual orientation*
designing services to provide safe, quality care and • Health literacy level* • Socioeconomic status
decrease health disparities. * denotes demographic variables that may be collected
on the patient- and patient population-levels only

Assessing the Need for C&L Services

As there is no “one size fits all” plan for providing cul- characteristics such as age, gender, race/ethnicity, primary
turally competent care, each organization must assess its spoken and/or written language, religion, health literacy,
needs and resources and plan accordingly. Before deter- and socioeconomic status.
mining which C&L services are most appropriate to
implement, it is important to collect and review data to Identifying different populations within the community
assess community and patient needs. allows an organization to respond to changing demo-
graphics, changing health needs, and the changing market.
Collecting Community-Level Data Demographic infor- Among the many benefits of understanding the service
mation about the service area population is essential to an community, several hospitals reported an increase in mar-
organization’s ability to fully appreciate and accommodate ket share as a result of their efforts to reach out to the com-
the needs of its community.18 Data collected at the com- munity and respond to the community’s health needs.
munity level provide insight into populations that actively
use hospital services as well as groups that may need tar-

“
geted outreach to increase access and interaction with the
organization. Demographic data may include a variety of “Collection of data is critical. Data shows
you who your population[s] [are] and what
17 Support for the systematic collection and analysis of data and its use in languages these populations speak. Further
[scrutiny] of the data allows the facility to see
quality improvement can be found throughout the current literature.

what services they are most apt to seek.

The HLC Report of Findings recommends that hospitals “implement a

It allows the facility to develop staff training based

uniform framework for the collection of data on race, ethnicity, and
language” and that "researchers should partner with hospitals to use

on their cultures as well as medical risks and

stratified quality measurement data to discern potential disparities and

tendencies. Data allows [human resources] to

develop follow-up measures of cultural and linguistic competence to
monitor actions toward improvement” (Recommendations 2-1 and

conduct an annual comparison of employee mix

2-6). Several national standards also require the collection of commu-

to community and patient load. If the patient data

nity- and patient-level data, including CLAS Standard 11, “health care

does not proportionately match the community

organizations should maintain a current demographic, cultural, and
epidemiological profile of the community as well as a needs assessment

data, then the facility must ask if there is a reason

to accurately plan for and implement services that respond to the

why that population is not accessing services.

cultural and linguistic characteristics of the service area,” and Joint
Commission standards require that medical records contain “the

What is missing from the services or are their

patient’s language and communication needs.”

24 18 As mentioned in Improving Communication — Improving Care, needs even addressed?”

–HLC TAP member

”
organizations should collect “population-level information about its
communication-vulnerable populations and their communication
needs” (Content Area 2, Performance Expectation 4.0). In addition,
it is recommended that “the organization works with community and
advocacy groups that service its community to collect information
about new and emerging racial, ethnic and language populations”
(Content Area 2, Performance Expectation 4.1).
CHAPTER 5: Collecting and Using Data to Improve Services

Some hospitals collected community-level data by able to confidently state that this information is collected
performing a community health needs assessment. consistently. Race and ethnicity data are often more dif-
Community health needs can be assessed through vari- ficult to collect. The current classification of the Office
ous methods, including conducting public forums, sur- of Management and Budget (OMB) does not identify
veys, or focus groups with members and leaders in the categorization of ethnicity beyond “Latino/Hispanic” or
community [23]. In addition, data are available regarding “non-Latino/Hispanic” [24]. This is insufficient when
racial and ethnic disparities in health care that hospitals organizations serve large populations that do not identify
can use to better understand the community they serve. themselves among the existing OMB classifications.
Data on age, gender, race/ethnicity, primary spoken In addition, collecting this information can prove to be
and/or written language, religion, socioeconomic status, sensitive both to patients and to the staff who are asked to
and other demographic characteristics can be accessed collect it.
from several sources, such as state, county, and municipal
departments of health; national census figures; and
United States Department of Education statistics. One Notes on Collecting Race and
Ethnicity Data
The Health Research and Educational Trust
hospital convened a steering committee to review demo-

Disparities Toolkit (www.hretdisparities.org) is a

graphic data from the community to determine commu-

free, valuable resource that provides recom-

nity health needs and plan for appropriate services.

mendations and guidelines to facilitate the

process of collecting race and ethnicity data [25].
Collecting Patient-Level Data Collecting data on age,

Included in the toolkit are training guidelines and

gender, race/ethnicity, primary spoken and/or written
scripts for staff to use when collecting these data
language, religion and other demographic characteristics
from patients.
during patient encounters can help organizations moni-
tor which populations currently seek C&L services and
what services should be provided in the future.19 In order
to make sure that the appropriate data are collected,
organizations may ask patients open-ended questions
such as, Is there anything else about you, your cultural back-

“ “We have been doing research on

ground, or your family that we should know that might help

the internet not only on census data but

us provide the best quality care for you? Questions such as

education data [as well] . . . The [steering]

these allow unique patient-level information to be cap-

committee will look at that and say, ‘Here’s

tured and addressed.

what our services looked like this year for our

patients; these are the major languages we
It is important, of course, to ensure that the data are accu-

interpreted, here are some of the difficulties

rate and systematically collected. As discussed in Chapter
we had, here’s what our community demo-
4: Building a Foundation, several hospitals have imple-
graphics look like-does it match up?’ . . . We
mented policies to identify and track a patient’s language
needs throughout the continuum of care, though few are are going to do this on an annual basis by
looking at internal and external data to see
how we are doing and [whether] our services
19 Improving Communication — Improving Care states that “when possible,

are structured correctly.” 25

information on an individual’s race and ethnicity is collected directly
from the individual,” and that an “organization ensures that informa-

–C&L services staff from a

”
tion on how individuals need to communicate is collected, including

northeastern hospital
primary language” (Content Area 2, Performance Expectations 2.1,
3.0, and 3.1). CLAS Standard 10 requires health care organizations to
“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.”
 CHAPTER 5: Collecting and Using Data to Improve Services

A northeastern hospital collected and used data on race, religious and spiritual care services, and special dietary
ethnicity, and primary language to strengthen patient- requests that are of a cultural nature.
centered care and staff recruitment processes, and to com-
pare clinical outcomes. As C&L services staff said, Collecting Data on C&L Service Use Providing language
“[We’re] making the commitment as an organization to services is essential to meeting the communication needs of
collect race- and ethnicity-related data. Along with that diverse patient populations. Collecting data on how often
comes the country of birth and primary language. It’s language services are used allows an organization to quan-
opened up a lot of opportunities for us to see how can we tify usage, justify a need for the services, and strengthen
take that information and make sure that it continues financial and staff support to provide those services.
with the patient throughout his/her stay here, and also Hospitals measured language service use by documenting
how can we use that information internally to strengthen the frequency of interpreter encounters during patient care.
or enhance some of our patient-centered care [and] our Interpreter encounters can be documented in a variety of
recruitment processes.” This hospital plans to incorporate ways, depending on an organization’s policies, such as
these demographic data into their strategic and business directly in the medical record or in interpreter logs that are
plans to better serve their community. This practice may maintained by the interpreter services department.
also be extended to include data on religious or spiritual Documentation may also include interpreter scheduling
preferences, as these data are also important for assessing databases, given that the organization has an electronic sys-
the need for C&L services. tem to plan and track encounters. The type of language
service used may also influence how usage data are col-
Other hospitals are using patient focus groups to gather lected. For example, records containing information on the
information regarding patient needs.20 A HLC TAP use of telephone interpreting services may be kept by indi-
member in support of this practice said, “Focus groups vidual departments rather than in a centralized location.
are . . . a way to collect data, but instead of relying on sur-
veys, which have a very low rate of return for the limited Documenting interpreter encounters may also be useful
English proficient (LEP) population, you get your data for the analysis of sentinel events. As communication
from the source, provided you can get enough patients to issues have been reported as the root cause of over 60% of
participate.” sentinel events [8], collecting data on interpreter encoun-

Monitoring C&L Service Utilization

To better evaluate an organization’s current C&L serv-
ices, it is critical to monitor how often the services are
used.21 Collecting data is one way to measure the fre-
quency of C&L service provision. Some of the services
that may be monitored include language services,

20 Improving Patient Care — Improving Communication encourages hospitals

to convene focus groups on a “regular basis to get feedback on the percep-
tions of care and communication needs of communication-vulnerable
populations” (Content Area 5, Performance Expectation 6.3).
“ “We tell them exactly what the
documentation needs to be. We tell them the
language or preferred method of communication
and the type of communication assistance
whether it was a telephonic, backup language
bank employee, or speech impaired.”
–C&L services staff from a

”
21 CLAS Standard 4 requires that “health care organizations must offer and
26 northeastern hospital
provide language assistance services, including bilingual staff and inter-
preter 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.” The HLC Report of Findings also recommends that “health
care interpreters should be used to facilitate communication during all
informed consent processes involving patients with limited English profi-
ciency, and cultural brokers should be used as a resource when a patient’s
cultural beliefs impact care” (Recommendation 4-2).
CHAPTER 5: Collecting and Using Data to Improve Services

ters can provide additional information. One southern emerge from these data, including the need for educa-
hospital had an adverse event reporting system that tion and training to increase awareness of the availability
included data on patients’ language needs and whether or of language services, to ensure that the services are
not an interpreter was provided. The appropriate docu- accessed and provided correctly, and to address compli-
mentation of language services, combined with an adverse ance problems with organizational policies or procedures
event reporting system that connects interpreter infor- for data collection. Data on interpreter encounters and
mation with event details, can provide further insight into language service use may also promote changes in staff
the effectiveness or weaknesses of specific interpreting recruitment that alleviate workload concerns.
methods and provide data for future studies.
Using Data to Improve C&L Services
One caveat of documenting interpreter encounters to Data collected before, during, and after the provision of
monitor language service use is that documentation C&L services can be used to identify areas for service
should be mandatory throughout the organization. improvement or expansion. Analyzing data from different
Sporadic or inconsistent data collection may inadver- sources and stratifying it by various factors can help
tently diminish the importance of providing language organizations strengthen their C&L services and address
services, based on an underestimate of the frequency of disparities in care for diverse patient populations.
use or an inaccurate representation of the need for lan-
guage services. Organizations are encouraged to develop Establishing a Baseline of C&L Services Before hospi-
system-wide policies to require the routine documenta- tals can evaluate C&L service improvements, it is impor-
tion of interpreter encounters throughout the continuum tant to assess the organization’s commitment to providing
of care (see Chapter 4: Building a Foundation). services to diverse patients and establish a baseline of
the services provided.22 A midwestern hospital hired a
Organizations may also consider extending the practice of
documenting interpreter encounters to address other C&L
services. Documenting patient encounters with religious

“
and spiritual care providers can help organizations meas-
ure the frequency of use for such services. It is also useful “[We] do root cause analysis, [and] the
to document information regarding patient dietary pref- language issues that come up in root cause
erences so that these preferences can be considered as care analysis are interpretation issues. Was [the
is provided. For example, if the patient has specific dietary information] adequately interpreted? Do we
preferences such as vegetarian, kosher, or halal, these really know what was interpreted? One of the
things we’ve done to assist with that is we
now have interpreters sign on [forms] that
should be documented so hospital services can be adapted

[identify that] they have interpreted for

to accommodate the patient’s specific needs (see Chapter

[patient] care, especially on consents.”

6: Accommodating the Needs of Specific Populations).

–CEO from a western hospital

Building Upon C&L Service Utilization Data
Quantifiable language service provision data can also
contribute to studies beyond merely understanding how
often patients use language services. For example, with
the practice of documenting interpreter encounters as a
model, data regarding the frequency of language service
”
22 CLAS Standard 9 advocates that “health care organizations should
27

use may serve as a foundation for inquiries into the effec- conduct initial and ongoing organizational self-assessments of CLAS-
tiveness of interpreter services, the allocation of resources, related activities and are encouraged to integrate cultural and linguistic
competence-related measures into their internal audits, performance
clinical outcomes for diverse populations, and patient improvement programs, patient satisfaction assessments, and out-
satisfaction studies. A number of staffing issues may also comes-based evaluations.”
 CHAPTER 5: Collecting and Using Data to Improve Services

consulting firm to conduct a comprehensive diversity audit demographic characteristics can help organizations better
across multiple categories, including supplier diversity, assess the need for C&L services. In addition, these data
building accessibility, policies, education programs, com- can be used in the analysis of service and technical quality
munication, and marketing. According to the hospital’s measures (including clinical outcomes) and adverse events
CEO, “[It gave] us a baseline on how we were [doing] in as a way to separate and stratify results by demographic
those categories. We could see, compared to the industry, category.24 Organizations are encouraged to use the demo-
that we are not doing too bad, or [that] we have a long way graphic data they collect to identify disparities in the care
to go. . . . We had our results given to our executives, which and services provided for diverse patients.
we prioritized and said, ‘Okay, based on all of that infor-
mation, we have to work on this.’ So we set some priorities.” Stratifying data by demographic variables can help hos-
pitals pinpoint areas in which patients from specific pop-
Obtaining Patient Feedback Collecting patient feed- ulations need targeted services or programs. For example,
back data following the provision of C&L services allows a southern hospital stratified their patient outcome data
an organization to evaluate those services from the by primary language, and the results prompted the
patient perspective. Patient feedback data can help hos- organization to translate patient education materials into
pitals determine the effectiveness and appropriateness of other languages to improve clinical outcomes for patients
their C&L services or suggest additional services. Several whose primary language was not English. Other hospi-
HLC study hospitals collected and reviewed patient com- tals stratified adverse event data by primary language, or
plaint and/or patient satisfaction data to identify issues stratified their performance and quality indicators by race
that could be better addressed by their C&L services. and ethnicity. Using data to better understand how cer-
One caveat to this practice is that patient complaint and tain populations receive care can also inform the way
satisfaction data are often collected through paper sur- organizations examine their core measures.
veys, and organizations may need to conduct focus
groups or adapt their written data collection tools to
accommodate C&L needs.23 Community resources and
leaders may also be helpful in both obtaining and assist-

“
ing in the analysis of patient feedback (see Chapter 7:
Establishing Internal and External Collaborations). “Focus groups are excellent ways to
‘hear’ about how well or not a facility is doing.
A northeastern hospital obtained patient feedback through They can also serve as an opportunity for
informal patient interviews with staff managers to iden- the community to learn about how the facility
tify patient care issues as a way to collect data to improve operates. If done correctly, they allow a
facility to learn from population groups who
may not participate in paper surveys.”
care and C&L services. In some cases, bilingual staff inter-
preted during patient interviews. The potential wealth of
–HLC TAP member

”
data obtained from direct interaction with patients can be
used for many purposes and provides an invaluable patient
perspective on existing and much-needed services.

Stratifying Data As mentioned earlier, collecting accu-

28
rate data regarding patient age, gender, race/ethnicity, pri-
mary spoken and/or written language, religion, and other
24 The HLC Report of Findings suggests that the “collection and analysis of
adverse event data by language, race, and ethnicity should be undertaken
23 As stated in CLAS Standard 13, “Health care organizations should and be standardized as a means to support patient safety initiatives”
ensure that conflict and grievance resolution processes are culturally (Recommendation 4-7). Improving Communication—Improving Care further
and linguistically sensitive and capable of identifying, preventing and advises that “the organization [cross-link] demographic information with
resolving cross-cultural conflicts or complaints by patients/consumers.” clinical quality measures” (Content Area 2, Performance Expectation 6.0).
CHAPTER 5: Collecting and Using Data to Improve Services

Although Exploring Cultural and Linguistic Services in the Conclusions

Nation’s Hospitals: A Report of Findings (HLC Report of This chapter highlights various considerations when devel-
Findings) advocates using technology as a tool to facilitate oping or evaluating current practices to collect and use data
data stratification,25 there were no practices identified in to improve C&L services. While many hospitals across the
this study that specifically addressed the use of informa- United States already collect these data, few hospitals have
tion systems to stratify data. As this report focuses on the developed systems for using them to guide service devel-
current practices performed in hospitals around the opment and improvement. The self-assessment questions
country, one possible explanation for the absence of tech- provided in chapter 8 were developed to generate ideas and
nology-based practices may be a lack of resources and discussion about identifying the types of data to collect,
technological infrastructure available in the present envi- existing databases that can be used, methods for collecting
ronment. However, it is also possible that organizations the data, and ways to use the data to improve services.
that have the technology in place do not use their data to
the fullest potential. Given the national attention to A thorough understanding of the need for C&L services,
developing and applying standards for health informa- dependable information regarding the use of those serv-
tion technology and electronic medical records, hospi- ices, and the usefulness of those data to improve C&L
tals must support the inclusion of race, ethnicity, and services can all contribute to an organization’s ability to
language as minimum, mandatory fields for the collec- identify and monitor health disparities and provide safe,
tion of C&L-related data. Data systems that support the quality health care to culturally and linguistically diverse
collection and facilitate the use of these data will allow patients. The data collected may also be used to inform
hospitals to refine their quality, performance, and out- short- and long-term organizational planning (see
come measures in order to improve C&L services. Chapter 4: Building a Foundation), help develop C&L-
specific services and programs (see Chapter 6:
Accommodating the Needs of Specific Populations), and
identify limitations in staffing and resources that collab-

“ “We’ve begun to break down not just

orative partnerships may alleviate (see Chapter 7:

who the patients are, but we’ve also begun

Establishing Internal and External Collaborations).

to look at patient care issues [and] overall

performance and quality indicators. . . .
We’ve just started in the last year to break
that down into different cultures or ethnicities
to see if there are any differences there and
draw correlations to see why one population
has a longer length of stay. Are there
resource issues? Socioeconomic levels?
Are there resources available to them after
discharge?. . . . [Can we] maybe change the
way we treat patients [as we go] forward?”
“ “The performance improvement cycle
starts with cycle thinking. . . . How do you
know if you’re providing good services or
not? What data do you have that shows that
you’re doing what you want to do and you’re
not providing services you want to provide?
If you’re not meeting your goals, then you
–A member of leadership move into the next part of performance
from a southern hospital

”
25 The HLC Report of Findings recommends that “health information
technology work groups need to determine practical ways of integrating
patient demographic data such as race, ethnicity, and primary
language into information systems” (Recommendation 2-5).
improvement which is planning, planning
for improvement.”
–A member of leadership from
a western hospital

”
29
 CHAPTER 6: Accommodating the Needs
of Specific Populations
Accommodating the needs of specific populations includes By building awareness of how communication con-
practices aimed at providing safe, quality care and decreas- tributes to patient safety and setting expectations for
ing health disparities for particular populations in the serv- effective communication at all levels of the organization,
ice community.26 Although all the practices mentioned in hospitals may be able to diminish resistance to C&L ini-
this report can help hospitals care for their diverse patients, tiatives and make effective communication a customary
the majority of practices reported by health organizations part of their overall services.
have a macro-level approach. In contrast, this chapter
focuses on micro-level practices designed to meet the chal- Some organizations may elect to start their training efforts
lenges of certain populations. The practices included also with high-level staff to ensure leadership buy-in for C&L-
relate to other themes in this report, but are placed in this related activities. One northeastern hospital developed a
chapter because they best reflect the organizational efforts senior-level training session that had a “focus on commu-
that directly address the language, cultural, and health nication as the cornerstone to patient safety and discusse[d]
literacy issues of specific populations. negative outcomes correlated to [limited English proficient]
and non-English speakers.” Hospitals may gain stronger
Promoting Staff Awareness through organizational support for C&L initiatives if members of
Training, Dialogue, and Support leadership champion efforts for better communication
In order to provide safe, quality health care for all patients, between staff and patients.
it is essential to integrate the concept of culturally compe-
tent care into staff training and education as a means Another way to enhance communication with patients
toward quality improvement.27 One of the challenges hos- is to provide staff education on how to work with a pro-
pitals reported is a lack of awareness among staff regarding fessional health care interpreter during medical encoun-
the importance of cultural and language (C&L) issues and ters.28 It is important to acknowledge that professional
how they affect patient care. To address this challenge, hos- health care interpreters are a key component of the med-
pitals are providing staff with training that encompasses a ical team and have abilities that extend beyond facilitat-
range of activities, from self-study educational materials to ing communication between patients and providers.
interactive group learning sessions. Given that interpreters have received the appropriate
training, they may also be used as cultural brokers to lend
Training to Support Effective Communication The insight into cultural practices and beliefs and identify
role of effective communication in patient safety has potential cultural conflicts.29
been well documented in the current literature [13].
Organizations can highlight the importance of commu- A number of hospitals provided staff with language
nication throughout the continuum of care by training courses such as English as a Second Language, accent
staff to improve their communication skills with patients. reduction, and one-day elementary medical language
classes. While such courses may alleviate some specific
26 CLAS Standard 1 states, “Health care organizations should ensure that communication barriers staff members may have, they
patients/consumers receive from all staff members effective, under-
standable, and respectful care that is provided in a manner compatible do not provide a means of bridging language barriers
with their cultural health beliefs and practices and preferred language.”
28 As mentioned in the HLC Report of Findings, “Health care interpreters
27 The HLC Report of Findings recommends that “hospitals should engage should be used to facilitate communication during all informed consent
30
staff in dialogues about meeting the needs of diverse populations” and processes involving patients with limited English proficiency, and
“hospital staff should be provided ongoing in-service training on ways cultural brokers should be used as a resource when a patient’s cultural
to meet the unique needs of their patient population, including regular beliefs impact care” (Recommendation 4-2).
in-services on how and when to access language services for patients with
limited English proficiency” (Recommendations 3-1 and 3-2). CLAS 29 Guiding principles and competencies for cultural brokering
Standard 3 requires that “health care organizations should ensure that programs are outlined in Bridging the Cultural Divide in Health
staff at all levels and across all disciplines receive ongoing education and Care Settings: The Essential Role of Cultural Broker Programs, available
training in culturally and linguistically appropriate service delivery.” at www.culturalbroker.info/index.html.
CHAPTER 6: Accommodating the Needs of Specific Populations

between staff and patients. Staff should be cautioned not Staff turnover is expected in hospitals, and it is important
to rely upon elementary second-language skills to com- to develop ongoing training to maintain a consistent staff
municate with patients; instead, the use of professional commitment to culturally competent care. A number of
health care interpreters is vital to avoiding patient- teaching hospitals worked with their training programs
provider miscommunication. to formalize cultural competency training and incorpo-
rate it into their residency programs. As a member of lead-
Several of the hospitals that provided staff language classes ership from a western hospital described, “We [have] a
reported that the classes were offered only to specific clin- three-year curriculum that includes topics on various cul-
ical staff, such as physicians. Hospitals should keep in mind tures. In particular, we talk about Hispanic, Vietnamese,
that the ability to communicate effectively is important for and Middle Eastern culture[s], teach[ing] [staff ] about
all staff, as it is not only physicians who interact and com- various aspects of [patients’] cultural needs, and use actual
municate with patients during the health care encounter. patient cases to [illustrate] needs.”

Training to Support Cultural Competence In addition to Cultural Competence

Learning Modules
addressing the importance of effective communication, hos-
pitals should also consider providing staff training around A number of learning modules related to cultural
cultural competence and sensitivity.30 While it is equally competence are available online including the
important to train on effective communication, training to Health Resources and Service Administration’s
support cultural competence serves a distinct function. Unified Health Communication 101: Addressing
Health Literacy, Cultural Competency, and
Limited English Proficiency (www.hrsa.gov/
healthliteracy/training.htm) [26], and the Office
Hospitals reported that staff education supporting cultural

of Minority Health’s A Physician’s Practical Guide

competence took many forms, including staff in-services,

to Culturally Competent Care (cccm.think

online resources, sessions with guest speakers, and specific

culturalhealth.org) [27].
cultural-focused classes. Topics varied from cultural tradi-
tions and rituals to the roles of traditional healers and faith
in the health and healing process. At one southern hospital,
for example, pharmacists lead training sessions for physi-
cians on types of herbal remedies they may encounter with
their patient population. As C&L services staff described,
“Our doctors have learn[ed] to become aware of different

“
herbal preparations and some of the various mixtures, and
“[We] do cultural competency training
for two reasons. We have a very diverse
they are aware of some of the medical side-effects of these

staff and want to develop cohesion between

mixtures. They have a wealth of experience in asking and

them, and the more understanding that we

assessing what patients are taking.” As a result, physicians

can create, the better the services will be.

may be better able to both collect a more accurate assess-

We try to train staff on the patient populations

ment of what their patients are taking as well as have a more

we serve. We don’t do enough of it and

complete understanding of the impact these remedies may
frankly we don’t do enough research to
have on their patients’ health. Staff training that supports
understand what culturally sensitive care is.”
cultural competence may also include gaining knowledge
31
–CEO from a western hospital

”
and skills for addressing cross-cultural encounters, such as
being aware of biases and tendencies for stereotyping.

30 Support for cultural competence training may increase when there is

clearer evidence of its effect on patient care. According to the HLC
Report of Findings, “More research is needed to evaluate the quality and
safety impact of diversity and cultural competence training provided to
health care workers” (Recommendation 4-8).
 CHAPTER 6: Accommodating the Needs of Specific Populations

Providing Staff with Educational Materials and Tools should not be a substitute for group trainings that give
HLC study hospitals used self-study materials and tools staff an opportunity to interact and openly discuss cul-
to educate staff about C&L issues. Resource books on dif- tural diversity issues.
ferent cultures were often reported, and a number of hos-
pitals developed visual aids such as cards for staff to use to Hospitals can better understand different staff perspec-
communicate with patients. As a member of leadership tives and possibly identify other issues that need to be
from a midwestern hospital described, “We don’t neces- addressed through in-person sessions that facilitate staff
sarily have an interpreter at the bedside 24 hours a day for dialogues. The importance of culturally competent care
every day of the hospitalization so there’s a lot of time extends beyond the limited English proficient (LEP)
where the nurse has to use his or her skills to talk with that population and can address communication issues that
patient [and] communicate basic daily needs. You can do affect populations with physical disabilities. One hospi-
that very simply through pictures, and you can show them tal developed hands-on role-play activities to provide
[text] in their language. . . . It’s just something for day-to- staff the opportunity to experience the perspective of
day to get by.” While these types of cards may be a rela- hearing- and vision-impaired patients.
tively inexpensive resource for staff and may feature many
of the issues commonly encountered by patients, such Using Technology to Support Communication
tools are far from exhaustive, only scratching the surface of Technological aids can be used to increase the efficiency
individual patient issues and making the health care con- and efficacy of interpreting services. Dual handset tele-
versation fairly one-sided. As hospitals and their staff use phones have reduced the inconvenience of passing a phone
various resources, they must remember that these are not back and forth between provider and patient or using the
substitutes for formal language training and/or quality lan- speakerphone feature during telephone interpreting
guage services. encounters. One northeastern hospital reported using
hands-free headset technology, and a member of their lead-
Online applications such as intranets have also provided a ership said, “We have made broader and better use of
new channel for hospitals to disseminate information sim- phone-based translation services over the last five years. We
ilar to that included in cultural resource books. One C&L have become a little more adept in using those services
services staff member from a midwestern hospital noted, through hands-free telephonic headsets. . . . Pre-admission,
“We’ve tried to direct more and more staff to the diversity
intranet, . . . [which provides] resources and information to
them. We have a couple of links on that site that give them

“
immediate translation of written materials as well. So, we’re
trying to keep it updated and make it easy to use at the “They had a ‘lunch-and-learn’ [session]
bedside. The intranet site has been a really excellent tool last year where people came and put on
because so many people are looking for something quick.” headphones so [that] they couldn’t hear.
[Physicians] would stand there and read
you medical instructions and [ask you to]
repeat back what they said. You would be
Hospitals should be aware that stand-alone self-study

[like], ‘Huh?’ . . . Or, you [had to] put on

materials can increase the likelihood of stereotyping,

these glasses so [that] you could not see,

given that only generalized descriptions of various pop-

and you were supposed to fill out a menu

ulations and cultures may be available in resource books
32 [as a diabetic].”
or visual aids.31 Educational materials such as these

–Human resources staff from

31 The HLC Report of Findings cautions that “once a patient’s race, culture,
ethnicity, language, and religion have been determined, hospital staff
and medical staff should be made aware of the tendency toward stereo-
typing in order to avoid making assumptions about patients”
(Recommendation 4-4).
a western hospital

”
CHAPTER 6: Accommodating the Needs of Specific Populations

histories, and pre-examinations can be done by our per- Creating an Environment that Meets
sonnel who are wearing hands-free sets so they can do Specific Patient Needs
physical examinations with patients and have telephonic In order to meet the needs of diverse patient populations,
interpretation at the same time. If you need someone to hospitals are developing or modifying existing services to
breathe deeply while you examine the solid organs in the provide safe, quality care to the specific populations they
abdomen, you can do that and have your hands available serve. These accommodations have involved alterations
and do what you need to do. That type of technical help to various aspects of the hospital’s physical space, pro-
has been very useful.” grams, and services to create an environment that is
inclusive of all patients.
One caveat to using the telephone for providing interpreter
services is that the interpreter misses nonverbal communi- Enhancing the Hospital’s Physical Space Hospitals are
cation between the patient and provider. Hospitals may undertaking numerous efforts to create a physical envi-
want to define, through organizational policies or proce- ronment that supports the diversity of their patient pop-
dures, which situations are appropriate for telephonic inter- ulation.32 The physical environment includes everything
preting and which require direct interaction [28]. from the layout of waiting areas and waiting rooms to
navigational signage and decor. One midwestern hospi-
Technology has also enhanced distance interpreting tal discovered that providing culturally competent care
through the use of video medical interpreting. The video requires an assessment of the hospital’s entire environ-
component adds another level of information to distance ment from the patient perspective. As diverse patient
interpreting, as interpreters are able to better see non- populations may contain groups other than LEP
verbal behaviors communicated by patients and staff. In patients, hospitals should consider all perspectives when
some hospitals, video medical interpreting has improved providing care.
the efficiency of in-house interpreters by eliminating
travel time from one patient to the next. Video medical
interpreting services provided by external vendors can
also alleviate the demand for in-house interpreters with-
out sacrificing the information obtained from nonverbal
cues.

Notes on Technology
Any technological upgrades may come with a
“ “We’ve done a series of audits of our space,
where people just go and sit in a waiting area
and see what happens. Or, [they] do a visual
assessment. If countertops are really
high and you’re sitting in a wheelchair, how
accessible is that? So, there’s been a very
sizable price tag so it may be worthwhile for hos- concerted effort around the environment.
pitals to experiment and pilot the use of these As we have done remodeling of patient care
technologies to look at a cost-benefit ratio. units, [and] as we’ve done remodeling of
Although each organization is unique, a possible other spaces, it’s with an eye toward how
proxy for this process would be to solicit and welcoming we are to all people.”
share information with other organizations until –C&L services staff from a
more robust research can be conducted in the
field. Hospitals should also consider staff needs
and any anticipated barriers to using new tech-
nology. While technologies in interpreting are
promising, organizations should keep in mind
that it is not the technology alone that enhances
care, but rather the way it is used by hospital staff
midwestern hospital

”
32 In Improving Communication — Improving Care, the AMA’s Ethical
Force Program advises organizations to create “a physical environment
that facilitates communication by fostering a feeling of welcome and
33

to better communicate and meet patient needs.

comfort for individuals from communication-vulnerable populations”
(Content Area 5a, Performance Expectation 1.0).
 CHAPTER 6: Accommodating the Needs of Specific Populations

Another significant component of an inclusive environ- Adapting Services to Address Cultural Beliefs Some
ment is the presence of directional signage and other criti- hospitals are altering or expanding existing services to
cal postings in a format that is appropriate and accessible.33 address the cultural beliefs of their patients.35 These types
However, achieving a patient-friendly environment encom- of adjustments are made on a case-by-case basis and can-
passes more than just having bilingual signage; health lit- not always be planned, nor can they be reflected in an
eracy levels should also be taken into account. As a member organization’s policies and procedures. Organizations
of leadership from a western hospital remarked, “It’s just should make an effort to be responsive to patients’
being sensitive to people in general. . . . Hospitals are like cultural needs and preferences.
mazes to some people. They can’t find [where they need to
go], even with great signage — it’s hard for them to inter- While some practices may result in significant changes
pret some signs.” To meet both literacy and language needs, to hospital services, other situations can be resolved fairly
hospitals may consider using universal health care symbols34 simply. A midwestern hospital relocated a female Muslim
or focus some attention on training those at initial points patient to a different unit to accommodate her cultural
of contact, such as information desk representatives, to be preference for a female provider. At a northeastern hos-
sensitive to and inclusive of diverse patients. pital, the CEO discussed how staff found ways to show
their respect for beliefs among the Chinese community:
Beyond redesigning the elements of an existing physical “You know [how some] people have a superstition
space, an inclusive environment may also require structural [about] the number 13? In the Chinese culture, it is
additions. Some hospitals are making adjustments to [around the number] four, so we do not put Chinese
accommodate the needs of both patients and staff. As a patients on the fourth floor or do anything with the
CEO from one northeastern hospital commented, “We number four. . . . You have to be responsive to that sort
have actually opened up a mosque, which is interesting for of [cultural belief ].”
a Lutheran institution. . . . [We] work[ed] with the Imams
in the community and with our physicians. We have quite
a number of physicians [and patients] who are Muslim, and

“
because they needed to pray during the day, there needed to
“You have to understand the values
be a spot to do it.” This practice reflects a structural modi-
fication targeted to a specific population and illustrates of the culture. The predominant value
the importance of engaging community leaders to improve for the Hispanic culture is family and
hospital services for patients and staff. relationships. . . . The Italians [in this area]
are the same way. It is critical that we provide
As hospitals consider changes to their physical space, data an environment to accommodate that.
Our Women’s Center has huge rooms. . . .
It’s nothing unusual if there is a mother
collection will play a key role in understanding the needs

in labor . . . [and] there might be 15-20

of patient populations and/or staff, and as the previous

people [in the room]. . . . It is critical that

example illustrates, collaboration may play a role in

we accommodate [cultural values].”

designing and implementing solutions. Understanding
the underlying values of patients’ cultures is essential to
–A member of leadership
from a western hospital

”
providing safe, quality care.

34 33 As required by CLAS Standard 7, “Health care organizations must

make available easily understood patient-related materials and post sig-
nage in the languages of the commonly encountered groups and/or
groups represented in the service area.”

34 The Hablamos Juntos project of the Robert Wood Johnson Foundation 35 The HLC Report of Findings recommends that “hospitals should take
developed and tested a set of universal health care symbols that is avail- advantage of the internal and external resources available to educate
able at www.hablamosjuntos.org. them on cultural beliefs they may encounter” (Recommendation 4-3).
CHAPTER 6: Accommodating the Needs of Specific Populations

As a human resources staff member from a midwestern Helping Patients Manage Their Care
hospital described, “We had a patient who wore a [cultur- Another way hospitals are better serving diverse popula-
ally symbolic bracelet,] and she had to have surgery. While tions is by offering services that allow patients to more eas-
we were trying to be attentive to the western philosophy of ily navigate the health care system.36 Hospitals are also
medicine, we didn’t realize that there were other things providing patients with education and training to help
going on. Someone realized later that they could put tape them take responsibility and advocate for their own health.
over the [bracelet,] in the [operating room] to maintain
sanitation but also make the place more welcoming for all Navigating the Health Care System Patient navigation
people who have different practices.” Although this reso- programs are designed to eliminate barriers and delays to
lution seems simple, it took initiative on the part of hospi- diagnosis and treatment through one-on-one contact [29].
tal staff to respect the patient’s beliefs and find an acceptable Patient navigators may assist patients with numerous issues,
compromise that was mutually beneficial. ranging from insurance to logistics (e.g., appointment
scheduling, transportation) to cultural beliefs to education.
Other hospitals mentioned adapting their food service Navigators are typically members of the community served,
programs, such as developing a halal kitchen and menu or are knowledgeable about the health care system, can com-
having their kitchen blessed by local religious leaders. municate effectively with patients and their families, and
Developing menus that are more attuned to the cultures of collaborate with external partners to coordinate follow-up
patient populations is not solely a food preference issue. and support services [30].
Food may play a role in specific traditions, as one CEO
from a northeastern hospital noted: “We had a sizable One western hospital used a patient navigator model tar-
Korean population of women who were delivering their geted to immigrant populations that integrates cultural
children here, and then all of a sudden, they disappeared. mediation, community engagement, patient navigation,
Why is that? Well, in the Korean culture, the birth of the case management, interpreting, and provision of care.
child and the care of the mother necessitate the serving of
seaweed soup to the mother post-delivery. Who would
know that unless you figured out why they were not com-
ing back? So we learned the hard way that . . . serving the
seaweed soup was [part of ] their culture.” This example
emphasizes the need to learn about and better understand
the community served. If this organization had not taken
the initiative to reach out to the Korean community, it
would have not discovered a simple accommodation to
“ “We had an organ procurement [issue,
in which] the spiritual leader could not leave the
room. [The patient’s culture believes] the soul
doesn’t depart without them....but [it’s] very
unusual to have anybody else in the operating
room during that particular procedure. But all
reconnect with this population. the right people were notified, and all the
arrangements were made, and we were able
Hospitals have also found the need to adapt direct patient to do that, to accommodate them, because we
care services. In order to meet the needs of their Somali knew how important it was for the family and
population, one CEO from a midwestern hospital everyone else involved.”
–A member of leadership from

”
described the need to add to their workforce, “For the
Somali [population,] we have a doula in our [obstetrics] a midwestern hospital
department. Somalis have a very different perspective about 35
gynecologic and reproductive health than [Western medi-
cine]. [The doula] is kind of like an advocate in labor —
someone who’s trained to know — not to be a physician 36 Improving Communication — Improving Care advises organizations to
have “programs to help communication-vulnerable populations navigate
extender but [rather] a patient extender.” the health care system to appropriately use health care resources”
(Content Area 5, Performance Expectation 2.0).
 CHAPTER 6: Accommodating the Needs of Specific Populations

A member of the leadership from the same hospital said, receive some training and education about how to care for
“[T]hese navigators have a capacity to do complex case the baby. She was not able to come back because of this
management, as well as education [and] some public health cultural practice — to rest for 30 days — so [the husband]
work, because they can bridge clinical encounters, go out was going to come in her place. Our practice was that mom
to the community, and talk about the implications for the comes in and receives that education, so we realized that
communities — kind of a public health vehicle.” However, we needed to . . . reevaluate our own practices.” The organ-
hospitals are cautioned that the implementation of a patient ization subsequently modified their post-childbirth train-
navigator program may require organizations to define ing to engage the father, thus accommodating the mother’s
boundaries between the roles of patient navigators and pro- need to rest for the allotted time period following labor.
fessional interpreters. If navigators will be used to interpret
during medical encounters, they should be assessed for Using Technology in Patient Instruction and
language proficiency in English and the target language. Education Some hospitals have used technology to dis-
tribute patient education, including online education via
Providing Patient Education and Training Patients streaming video technology in sign language for deaf and
must have the appropriate education and training to hard of hearing patients as well as language translation
make informed decisions, actively participate in, and software to provide educational and discharge materials
manage their care.37 Hospitals employed several practices in patients’ primary languages. Hospitals have used the
to educate patients in their primary language. Spanish internet or an organizational intranet to create patient
interpreters have specifically been used in obstetrics (OB) education materials in multiple languages. At a western
and neonatal intensive care units to assist patients with hospital, human resources staff discussed their use of
discharge instructions, which resulted in decreased revis- electronic patient education software to create docu-
its to the emergency room. According to the leadership at ments that meet language needs, “[F]or the nursing side,
a western hospital, “[We] recognized there [were] a large we have a patient education [computer] program. [It has]
number of moms and babies returning to the hospital whatever topic you want to teach to your patient to take
after discharge. In investigating that, [we] realized that home and to read. It comes predominately in English
the problem was that they weren’t understanding the and Spanish. . . . There are up to ten languages provided
information that they were being sent home with. . . . for certain topics.”
[Now] if you go up to OB, you will find everything you
can possibly imagine. Information can be communicated
correctly so that [new parents] can leave the hospital and
know how to care for that baby and know how to care for
themselves. . . . There was just an absolute decrease in the
number of returns we had of new moms and babies com-
ing back. It was a simple solution to what could just turn
out to be a disaster if [patients] don’t have the right info.”

In an effort to meet both the educational and cultural needs

of the patient population, hospitals may also alter how they
“ “One of the programs we have [includes]
case managers that go into the community
and areas particularly where we have
non-English speaking individuals and are
really case finders/case managers, where
they can work with those populations and
provide education to account for traditional customs. A encourage them to seek care when needed.”
36 –CEO from a western hospital

”
member of leadership from a northeastern hospital
described, “[After childbirth,] the mother had been dis-
charged. What was needed was for her to come back and

37 Joint Commission standards require that patients receive “education

and training specific to the patient’s needs and as appropriate to the
care, treatment, and services provided.”
CHAPTER 6: Accommodating the Needs of Specific Populations

Hospitals should remember that although technology is a cultural needs of the patients they serve. In some instances,
more convenient or efficient channel to convey informa- hospitals designed culturally centered programs to help
tion, it is the quality of the message and materials that will bridge cultural barriers in the understanding of health and
ultimately determine whether the needs of patients are healing. For example, one western hospital faced challenges
being met. With online translation tools, hospitals should when reconciling ideas between practices in Western med-
remind their staff that language translation software pro- icine and the traditional healing practices of the American
vides literal translations, and therefore, they should have Indian population they serve. A C&L services staff mem-
written policies about the editing process that is required to ber described, “In Native medicine there’s no diabetes. The
verify the accuracy of the translation.38 Without professional illness a patient carries has another diagnosis in Native
translators to edit electronically translated documents, the medicine . . . so then as a patient, you will have two ill-
danger is very real that incorrect information could be con- nesses, [one diagnosed by Western medicine, and another
veyed to patients, compromising patient safety and care. diagnosed by Native medicine]. . . . The practitioner, physi-
cian, and nurses have to have some general understanding
Notes on Language Translation about the cultural belief and the legal issues so that they
Software teach [patients] accordingly — or provide medications
Organizations should be aware that although lan- accordingly.” This hospital formally established a Native
guage translation software and online translation medicine program and a Traditional Healing Committee
tools can make some processes more efficient, that worked to integrate traditional healing practices into
these resources may only provide information in
one direction, such as tools that only provide
the Western medicine practiced in the hospital to better

instruction. When such programs are used alone,

serve their American Indian community.

there is no way for health care providers to ascer-

tain the level of patient understanding or respond
In other cases, culturally centered programs provided serv-

to patient concerns and questions. Hospitals may

ices that better recognized the distinct needs of various

consider supplementing the use of electronically

groups. One midwestern hospital developed a tele-psychi-
translated patient education documents with pro-
atry program to better serve the needs of their deaf and
fessional interpreters to facilitate communication
hard of hearing patients. A C&L services staff member
between patients and providers.
pointed out, “We have a psychologist/psychiatrist who

Establishing Centralized Programs

that Meet Specific Needs of Large
Populations
For large populations that may comprise a significant
number of patients, it may be necessary to develop cen-
tralized programs within an organization to implement
system-wide services that address specific patient needs.
These types of programs are often created in response to
diverse cultural and religious needs.
“ “In psychiatry, we have culturally focused
units —Spanish-focused, gay-focused,
Asian-focused. We have had waivers on
positions that would require a person to go
through specific classes before being hired
for [one of these] positions. This model in
psychiatry has worked well, [and] it is a big
Developing Culturally Centered Programs Hospitals have attractor for staff to work here.” 37
–CEO from a western hospital

”
developed formalized programs built around the unique

38 As recommended by Improving Communication — Improving Care,

organizations should ensure that “translations from English are
independently evaluated and checked for accuracy” (Content Area 5b,
Performance Expectation 8.1).
 CHAPTER 6: Accommodating the Needs of Specific Populations

speaks sign language and through video streaming gives tation services to patients, but offer guidance as a group on
appointments to people over their home computer. . . . how the hospital can engage their community.
[They provide] mental health and behavioral health
sessions [and] consults.” Spiritually or culturally centered committees can play an
important role in the development of centralized programs.
Similarly, a western hospital created a culturally focused In addition to the use of focus groups, as described in the
psychiatric unit that accommodates several populations Chapter 5: Collecting and Using Data to Improve Services,
in their service community. Culturally centered programs these committees can inform the development and imple-
need to be supported by targeted recruitment and cul- mentation of such centralized programs.
tural competency training, and the cultural competency
training that this program’s staff completes is both ongo- Conclusions
ing and evaluated for efficacy. As described by a human Accommodations targeted to the needs of specific popula-
resources staff member, “We have certain things such as tions evolve as hospitals search for solutions to the chal-
mandatory cultural competency testing. We require that lenges of providing care to their diverse patients. To ensure
all of our staff have at least one training . . . and monthly organizations meet changing staff and patient needs, the
unit-based updates. I think where [we see results] is development of services and activities tailored for specific
around patient relationships.” populations should be a continuous process. While the
practices outlined in this chapter show positive steps
Developing Religious or Spiritually Centered Programs toward the delivery of culturally and linguistically appro-
Along with meeting the cultural needs of patients, hospi- priate care, they also indicate the complicated reality of the
tals have established programs to meet various religious long road ahead. Although knowledge, field experience,
and spiritual needs of patients.39 A human resources staff and technology have improved the delivery of C&L serv-
member from a western hospital noted, “One thing that ices, hospitals need to consider the balance between con-
has been identified on the patient side was more support, venience, cost, patient safety, and quality. Chapter 8
spiritually . . . [The hospital] started a program a year ago, includes a self-assessment tool hospitals and other health
and the employees are volunteering to give their skills to care organizations can use to evaluate their current C&L
help. Thirty-five percent of our patients are Catholic, so services with respect to the specific populations they serve.
we wanted to meet that need. When [patients] are in the
hospital, [they feel] a need to be connected with their

“
faith. What we found is that we have far more employees
“We have a Spiritual Care Advisory
willing to help with religions [in addition to Catholicism].
Committee comprised of community clergy.
We took [these 60 volunteers] through a six-week train-
ing on praying in other religions.” A northeastern hospi- The local Imam of the mosque in [the neighboring
tal addressed the religious needs of their population by community] is on it. The priest from the Catholic
expanding their annual child remembrance services to church next door is on it. . . . We have a rabbi
include four different religions. from a temple in [a neighboring community]
involved as well, so it is a whole cross-section
of people — the first council for [the Church of
Jesus Christ of Latter-Day Saints] is also on it.
Twenty percent of hospitals reported that they had devel-

They are our advisory committee; [and] they talk

oped interfaith chaplaincy programs comprised of leaders
38 with us every year about how to promote our
from a variety of different religious groups. In some

programs in the community.”

instances, these religious leaders not only provide consul-

–C&L services staff from

a western hospital

”
39 Improving Communication — Improving Care advises that “the organiza-
tion’s scheduling of communication and educational events [be] sensi-
tive to relevant religious and cultural observances” (Content Area 5a,
Performance Expectation 6.0).
CHAPTER 6: Accommodating the Needs of Specific Populations

As organizations create services and resources for specific

populations, these initiatives will likely include elements of
Chapter 4: Building a Foundation, Chapter 5: Collecting

“ “We have had to modify some of our

and Using Data to Improve Services, and Chapter 7:

policies with respect to religious preferences.

Establishing Internal and External Collaborations. As a

We have a population of Jehovah’s

member of C&L services from a midwestern hospital
Witnesses who use our facility and who
described, “[The doula program] came out of dialogue with
do not believe in blood transfusions [during]
women from the community that we were able to bring in
surgery, so our medical staff have created
[to] talk about their birth practices [and] our birth prac-
tices. . . . We had a series of three luncheons. We some policies for bloodless surgeries with the
literally sent vans out to go pick women up and bring them Jehovah’s Witness leadership within the
here to have a dialogue. It was as informal as that. community to make certain that we
It [developed] into the doula program that we [now] have.” are consistent with the guidelines that
As this example shows, elements of each theme can con- they have set up.”
–CEO from a western hospital

”
tribute to the development of programs that accommodate
the needs of specific populations.

39
 CHAPTER 7: Establishing Internal and
External Collaborations
Collaborative practices encompass those that bring together Bringing Stakeholders Together Beyond the Diversity
multiple departments, organizations, providers, and indi- Committee While bringing together a diverse committee
viduals to achieve objectives related to culturally and lin- or task force is important, interdepartmental collaborations
guistically appropriate care. Collaborative partnerships, should not be exclusive to specialized “diversity groups.”
both internal and external, can provide a conduit for under- These types of collaborations could be utilized to imple-
taking the practices outlined in Chapter 4: Building a ment any of the practices outlined in the previous chapters.
Foundation, Chapter 5: Collecting and Using Data to By gathering a diverse group of stakeholders to work
Improve Services, and Chapter 6: Accommodating the together on projects and tasks related to cultural compe-
Needs of Specific Populations. Collaborations can help hos- tence, the varying perspectives that this type of group can
pitals engage their community, share information and give will help guide organizations through various steps in
resources, and improve the care they provide. the process. First, in defining issues, they can provide insight
and identify specific needs to be addressed. Second, they
Working Together within the Hospital can guide implementation as there may be existing resources
Within each hospital, different stakeholders should be within each department that can be pooled together or
brought together to develop, implement, evaluate, and existing processes that can serve as a template. Third, they
improve initiatives aimed at meeting the needs of diverse will play an important role in pilot testing, evaluating, and
patients.40 For this reason, when implementing any of the providing feedback for refining programs and materials.
practices outlined in the previous chapters, diverse indi- Having feedback from multiple groups at a pilot stage may
viduals across the organization should be involved, repre- help refine processes, identify any areas that require tailor-
senting a range of different departments, positions, ing, and reveal any critical gaps or lagging processes. Despite
professional levels, racial/ethnic backgrounds, etc. the benefits that these types of interdepartmental collabo-
rations can bring, they do not come without their chal-
Establishing a Cultural Diversity Committee Involving lenges. Bringing together such varying departments,
staff from across the organization throughout the develop- perspectives, personalities, and cultures can cause points of
ment and implementation of culturally competent care is disagreement to surface, which may generate tension.
essential to helping identify all the needs to be addressed However, as contentious as these discussions may become,
and to provide feedback on solutions to meet those needs. they may also help alleviate existing tensions among these

Bringing Diverse Stakeholders

Along these lines, among the most common practices

Together to Form a High-Level

reported by participating hospitals is the establishment of
a Cultural Diversity Committee comprising administra-
Task Force
The practice of bringing diverse stakeholders
tion, management, and employees. Some of these com-

together can add another level to the idea of the

mittees also included members of the community or

high-level task force introduced in Chapter 4:

patient population. These groups are often tasked with pro-
Building a Foundation. The importance of the task
viding mentorship, education, information sharing, and
force described in chapter 4 is that it is charged
other activities related to offering cultural and language
(C&L) services. with the responsibility of driving cultural compe-
tence. The Cultural Diversity Committee brings
together diverse stakeholders from throughout the
40 Improving Communication — Improving Care suggests, “Regular evalua-

40 organization to discuss and implement C&L-

tions include talking to workforce members, community liaisons and

related initiatives. These two practices are not

individuals from communication-vulnerable populations about both

mutually exclusive. Ideally, a C&L-related task

positive and negative aspects of the organization’s communication pro-
grams and strategies” and “the organization responds to the results of

force or committee would be comprised of diverse,

evaluations by having leaders, workforce members community mem-

multidisciplinary stakeholders and hold the power

bers, and individuals from the populations it serves work together to
develop solutions and make changes to plans, policies, procedures and

and responsibility to oversee and drive initiatives.

educational programs” (Content Area 6, Performance Expectations 1.2
and 8.0).
CHAPTER 7: Establishing Internal and External Collaborations

groups as they have an opportunity to voice their opinions, However, sharing existing materials can also require over-
hear from others, and work toward a common goal. coming any organizational “red tape” that may prevent
this type of collaboration. Additionally, although hospi-
Building Bridges with Other Hospitals tals may be able to contribute to a common pool of
External collaborations — with other hospitals or health resources that meet several needs and are available in a
care organizations — are equally important.41 As hospitals variety of languages, there will still be gaps, and existing
find ways to share their resources with each other, they materials may not be adequate.
may be able to better address challenges such as limited
resources and high costs for developing new materials and Pooling Resources Together Bringing together the
programs. Resources and programs that may benefit from resources of multiple hospitals to create new materials that
collaboration include staff training in cultural competence, meet the needs of diverse patient populations is one poten-
interpreter services, signage and written materials available tial way to fill persistent gaps in existing materials. One
in multiple languages, and resources to patients who speak midwestern hospital collaborated with a group of area hos-
languages not commonly encountered by the hospital. pitals to produce a set of translated materials for use among
the group. As a member of leadership from this hospital,
Sharing Existing Resources Many hospitals around the “[The] hospitals all together received grant funding and
country provide care to patients with similar needs and face developed a web site that is accessible to all hospitals [and
common challenges in providing culturally and linguisti- which] has translated materials in multiple languages on all
cally appropriate care to diverse populations. While each of the basic health care needs.” This hospital also reported
hospital is unique, they may share a common need for taking part in a collaborative to create a cultural compe-
resources, which can bring organizations together to avoid tency index that addresses the health care needs of 50 or 60
“reinventing the wheel” each time they take on C&L- ethnic groups in addition to 25 or 30 cultural belief sys-
related activities. In some cases, sharing existing resources tems. The index provides links to translation services and
can help resolve issues related to time, finances, and staff. resources for patient health information and education
materials. Since its initial development, this particular hos-
For example, as part of a grant they received, one western pital has posted this index on their intranet.
hospital reported creating a web site for sharing informa-
tion about the different cultures that are common to their
geographical area. As the CEO of the hospital commented,
“We can get information [about] a variety of patient pop-

“
ulations and present it to [staff ] in a way that they under-
stand.” While the development of this web site is worth “We are part of a local collaborative, where
mentioning, what is more interesting about this example is six or seven different health care systems
that the organization took this project a step further by have come together and said, ‘We don’t
sharing it with other hospitals that serve similar commu- all need to translate all of our diabetic and
nities. Since its development, this web site has been used by 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
other hospitals across the country and continues to receive

take our letterhead off of that information.’

support from grant funding. By sharing resources this way,

We can use that information across

hospitals may find new methods of filling gaps in their own
41
the system.”
materials and programs. Alternatively, this type of sharing
may also help hospitals develop materials they do not have
–Human resources staff from
a midwestern hospital

”
the resources to produce on their own.

41 Recommendation 4-3 from the HLC Report of Findings supports this idea:
“Hospitals should take advantage of the internal and external resources
available to educate them on cultural beliefs they may encounter.”
 CHAPTER 7: Establishing Internal and External Collaborations

By pooling resources to create materials in this way, hos- the research framework suggests that “in hospitals that are
pitals are essentially creating better tools that they can all affiliated with health professional teaching programs (such
use. As a human resources staff member noted, “[By as medical schools, nursing schools, and schools of public
working together,] we can make sure that the informa- health), there is an effort to interact with the teaching pro-
tion is accurate, but we can [also] be more effective with gram to share information about providing services to meet
the information we have.” the diverse cultural and linguistic needs of patients” [3].
This type of opportunity is not exclusive to hospitals affil-
If hospitals can find other health care organizations that iated with health professional teaching programs. One west-
have similar needs or serve a similar mix of patients, they ern hospital mentioned that they are participating in a
can come together to create tools or translate existing foreign nurse program with a local community college. As
materials to better serve their patients. However, in some a member of their human resources staff said, “We take
cases, it may be difficult to find a hospital with similar individuals who are already here in this state who are
needs, or there may be organizational barriers or restric- licensed in another country, and they go through a retrain-
tions to jointly developing, owning, and sharing materials. ing to become nurses here in the United States.” Programs
Working with other hospitals and health care organiza- such as these have the potential to provide hospitals with a
tions is a great step forward, but collaborative opportuni- more diverse workforce. As the CEO remarked, “Our hope,
ties can be expanded by involving other disciplines, our desire, is to hire many more bilingual staff members.”
groups, and the community in general.
One issue to keep in mind with retraining foreign-born
Engaging the Community staff is that literacy and language competency need to be
Involving the community and making use of external assessed in both the target language and English. As one
resources can help hospitals take steps toward developing TAP member suggested, this practice could be improved
a more diverse workforce, bridging cultural barriers, and if coupled with English as a Second Language classes for
becoming a more active part of the community.42 the nurses being recruited and retrained.

Community Partnerships to Create a More Diverse

Workforce Collaboration with academic institutions and
training programs has the power to provide a comparable
opportunity for hospitals that are not affiliated with health
professional teaching programs to establish potential sources
for recruiting and training a more diverse workforce.43 In

“
Exploring Cultural and Linguistic Services in the Nation’s
“We are working with [a] county hospital.
We want to be able to share our resources,
Hospitals: A Report of Findings (HLC Report of Findings),

[especially for] the [less common] languages

we see like Arabic, Croatian, etc.”
42 Practices that engage the community have been recommended by both the
HLC Report of Findings — “Hospitals should make use of the community

–C&L services staff from

resources available through community networks, collaborations, and part-

a western hospital

”
nerships, including the involvement of community members from diverse
cultures and language groups on formal boards and in hospital planning
processes” (Recommendation 6-1) — as well as CLAS Standard 12:
“Health care organizations should develop participatory, collaborative

42
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.”

43 Improving Communication — Improving Care recommends, “The organ-

ization partners with educational institutions and other community
organizations to achieve workforce goals and enhance services, especially
for communication-vulnerable populations” (Content Area 4,
Performance Expectation 3.0).
CHAPTER 7: Establishing Internal and External Collaborations

Partnerships among hospitals, local training programs, nerships should not be exclusive to traditional healers. As
and academic institutions are not limited to retraining many patients may have cultural needs related to religious
foreign-born medical staff. Hospitals should consider beliefs, hospitals should develop relationships with local
reaching out to any local programs that provide training religious leaders and institutions to provide resources and
in bilingual medical interpretation, giving students the guidance for serving patients with specific needs. The
opportunity to complete an internship or shadow pro- National Center for Cultural Competence’s Sharing a
fessional healthcare interpreters. Alternately, if these types Legacy of Caring: Partnerships Between Health Care and
of programs do not currently exist in the community, Faith-Based Organizations may help organizations explore
local colleges or training programs can work together the potential benefits and barriers to developing these types
with hospitals to establish partnerships to develop and of collaborations [34]. In addition, hospital chaplains often
train bilingual staff. Obviously, developing new training serve as cultural brokers, helping hospitals address patients’
programs requires both time and money, which can be cultural needs. While these partnerships may help fill exist-
difficult to find, but a number of partnerships have made ing gaps in a hospital’s C&L-related services, they can also
available the structure of their programs as well as some present major challenges. As one TAP member mentioned,
lessons learned, upon which hospitals can draw [31-33]. this type of collaboration, such as allowing traditional cer-
emonies to be performed at the hospital, may require a
Additionally, partnerships should not be limited to colleges change in organizational policies. Staff training on access-
and secondary education institutions. A western hospital ing these services and understanding their role in the pro-
mentioned working with a local high school to financially vision of culturally competent care may also be required.
support high school students who want to go to college for
health care interpreting. As many high school students are Becoming an Active Member of the Community
unaware of such opportunities, it is important to reach out Engaging the community also involves reaching out to
to the community and establish relationships with local community members and raising awareness of services
schools. However, one TAP member commented, “Few available at the hospital. These activities can include such
colleges offer medical interpretation as a career,” so this type strategies as advertising and recruitment drives; however,
of collaboration may not always be an option. Therefore, community interaction can consist of activities that are
hospitals should supplement their recruitment efforts with considered more grassroots. One southern hospital, for
ongoing training of existing bilingual staff.

Using Community Leaders to Bridge Cultural

Barriers To better address cultural or religious health

“
beliefs, hospitals can develop relationships and collabo-
“We go to [high school] job fairs. Having a
bilingual recruiter helps us a lot with these
rate with cultural or religious leaders in the community

efforts [because] they can influence the ideas

to meet patients’ needs. One western hospital, for exam-

that some students may have about getting

ple, discussed their cooperative relationship with a local

into health care or nursing. We just had a

American Indian medicine man. Through such partner-

scholarship for education aimed at vulnerable

ships, traditional healers are on hand to provide guid-

populations. By [receiving] that, [students] are

ance to patients and staff on how to bridge gaps between

committ[ed] to com[ing] back here and

traditional and Western medicine.
work[ing] for us.” 43

–Human resources staff from

The practice of developing partnerships with traditional
healers is not limited to any particular culture. A shaman,
for example, may help bridge cultural barriers for Southeast
Asian populations, or a curandero may help address the
needs of patients of Mexican descent. However, these part-
a western hospital

”
 CHAPTER 7: Establishing Internal and External Collaborations

example, shared that they hired a Hispanic staff person to Conclusions

work with lay health educators in the Hispanic commu- Collaboration, whether internal or external, may provide
nity to educate community members on how to use the new avenues for hospitals currently undertaking cultural
hospital. A western hospital mentioned that they have competence initiatives. There is no doubt that collaboration
made formal efforts to talk to the community and inform needs to play a role in all the practices outlined in this report.
them about the various services the hospital provides. This For example, as hospitals develop C&L-related organiza-
type of outreach can both raise awareness of available serv- tional policies and procedures, leadership should engage and
ices and provide a means of establishing organizational bring together stakeholders from multiple departments in
commitment and a level of trust within the community. order to understand the environment (supports, constraints,
etc.) in which current procedures are being carried out (see
As hospitals reach out to their communities, they should Chapter 4: Building a Foundation). Collaboration may also
also consider ways in which they can provide avenues for have implications for data collection (see Chapter 5:
making community services more cohesive.44 To do this, Collecting and Using Data to Improve Services) as hospitals
hospitals need to identify the various services that their may find external organizations that they can work with to
patients may encounter throughout the continuum of care. collect community-level data. Additionally, partnerships with
One northeastern hospital, for example, trains their inter- external organizations may increase access to resources that
preters to raise awareness of public assistance programs and supplement the services provided by the hospital (see
the State Children’s Health Insurance Program (SCHIP) Chapter 6: Accommodating the Needs of Specific
to help with hospital reimbursement. A CEO from a west- Populations). Building active relationships with cultural bro-
ern hospital mentioned that their web site includes, “a lot kers, traditional healers, chaplains, religious leaders, and other
of other programs that . . . provide non-health care sup- individuals may enhance and extend the hospital’s existing
port —food coupons [and] other types of temporary hous- C&L services. While collaborative efforts come with their
ing assistance that we can provide to patients when we need own challenges, building partnerships that bring together
to.” Alternatively, hospitals can also provide resources on the champions of culturally and linguistically appropriate
local adult learning programs for patients with limited care has the potential to move the entire field forward. The
health literacy skills.45 These efforts may help hospitals self-assessment questions provided in chapter 8 can help hos-
develop relationships to revise existing materials or create pitals and other health care organizations further explore
new materials that not only meet patients’ language needs opportunities for internal or external collaborations for
but also their health literacy needs.46 better meeting the needs of diverse patient populations.

44 Improving Communication — Improving Care recommends that a health

“ “[The director of community outreach and

care organization work “with its community partners to facilitate com-
munication outside of clinical encounters, emphasizing the needs of

interpreter services] has taken a step with

communication-vulnerable populations.” Once this partnership is

the interpreters — that they should not just

established with the community, the AMA’s Ethical Force Program sug-
gests that they “work together to identify resources, services and assets

function within the four walls of the hospital;

available within the community to aid in communicating about health

they should actually be out in the community. . . .

and health care, especially for communication-vulnerable populations”

This hospital, through its interpreter services and

(Content Area 3, Performance Expectations 3.1 and 3.2).

other services as well, has truly gone out and

45 Improving Communication — Improving Care suggests that “the organi-

has mined the intelligence that’s out in the

zation [work] with the populations it serves and community organiza-
tions to help improve health literacy” (Content Area 5c, Performance

community — the epidemiology that’s out in the

Expectation 7.0).

44 46 Recommendation III from “What Did the Doctor Say?:” Improving Health community, the different religious groups, and
people living in the community — and said,
Literacy to Protect Patient Safety suggests that health care organizations

‘How can we best react to that?’”

“refer patients with low literacy to adult learning centers, and assist them
with enrollment procedures” and “encourage partnerships among adult

–CEO from a
educators, adult learners, and health professionals to develop health-

northeastern hospital

”
related curricula in adult learning programs, and conversely . . . assist in
the design of patient-centered health care services and interventions.”
CHAPTER 8: Tailoring Initiatives to Meet the
Needs of Diverse Populations:
A Self-Assessment Tool
Exploring Cultural and Linguistic Services in the Nation’s tool is designed to help hospitals and other health care
Hospitals: A Report of Findings (HLC Report of Findings) organizations discuss and explore current C&L practices in
showed us a snapshot of 60 hospitals at different points order to identify potential gaps and areas for improvement.
of the cultural competence continuum [3]. It also con- We believe that the tool presented here will stimulate these
firmed that hospitals are challenged to meet the diverse moments of discovery and help staff see their C&L serv-
cultural and language (C&L) needs of the patients they ices in the context of the organization as a whole.
serve. Until evidence-based practice standards for cul-
tural competence are developed, hospitals must continue How to Use the Tool
to meet these diverse needs as best they can. The goal of this tool is to engage diverse staff members
from different sectors of the organization to come
Hospitals are complex institutions, each with unique demo- together and explore how they are currently addressing
graphic, regional, historic, and financial contexts. In order patients’ C&L needs. The benefit of the tool is that it
for C&L practices to be effective, they should be designed allows organizations to think broadly about how they
to meet the needs of the organization and its patients. It is meet the needs of diverse patient populations and con-
our hope that this report and the self-assessment tool con- sider how processes may be improved upon to reflect the
tained in this chapter will help hospitals and other health organization’s focus on achieving optimal patient out-
care organizations tailor initiatives to provide culturally and comes and reducing health disparities.
linguistically appropriate care.
Bringing People Together Organizations will likely find
The Self-Assessment Tool different ways to use the self-assessment tool. Some
Site visits for the Hospitals, Language, and Culture (HLC) organizations may decide that they wish to bring
study brought together individuals at each hospital for together a multidisciplinary group or create a high-level
focused discussions about how care is being provided to task force — as described in Chapter 4: Building a
patients from culturally and linguistically diverse back- Foundation and Chapter 7: Establishing Internal and
grounds. The interview sessions were exploratory, allow- External Collaborations — to go through the self-assess-
ing participants to share their experiences and challenges ment questions. Another option is to bring together
in meeting C&L needs. We found that bringing staff smaller groups, drawing from different organizational
together to dialogue about how their organization was levels or disciplines. Some organizations may decide to
meeting these needs was informative not only for the appoint either a team or individual to spearhead the
study, but for participants as well. Hospital staff often process. It may also be useful to have a group facilitator
found themselves viewing these issues from a new per- help guide discussions and give members of the group
spective and generating new ideas for approaching these an opportunity to provide input.
situations.
Bringing people together to explore C&L issues can be a
The self-assessment tool at the end of this chapter can be useful way to share information and ensure that everyone is
used to guide these types of discussions and engage mem- on the same page. In addition, individual interviews can

45
bers of the organization in conversations about the needs, provide details and enrich the information collected.
resources, and goals for providing the highest quality care Organizations may consider using a combination of meth-
to every patient served. The tool consists of questions, gen- ods to conduct their self-assessment. While some organiza-
erally open-ended, that are built around the concepts out- tions may choose to complete their assessment in a one-day
lined in chapters 4 through 7. The questions are not session, others may prefer a series of shorter meetings.
evaluative, and there are no right or wrong answers. The
 CHAPTER 8: Tailoring Initiatives to Meet the Needs of Diverse Populations:
A Self-Assessment Tool

Methods for Conducting

interpreting service, but discover that staff do not use it. To

Self-Assessment
understand why this disconnect occurs, the organization
• Focus groups • Small-group interviews
should determine what factors contribute to the underuse
• In-services • Staff retreat
of the service — perhaps staff is unaware that the service
• Lunch meetings • Targeted interviews is available or is not comfortable using it.
• Seminar series
We encourage organizations to have frequent dialogues
about the practices that are employed, including how the
Choosing Participants Regardless of which method is practices are being evaluated. Asking questions such as Are
used, it will be important to collect information from a the practices meeting their intended aims? How effective are
range of staff representing different disciplines and levels. these current practices? How well are they fitting in with other
A diverse group of stakeholders will bring varying expe- hospital processes/services? Are there any barriers that still need
riences with C&L issues to the table and provide a more to be addressed? What improvements can be made? Have the
well-rounded view of how the organization is currently practices resulted in any unintended consequences? should be
meeting the needs of diverse patients. a continuous part of ongoing organizational improvement.

Potential Participants Organizations may also consider conducting a self-assess-

• Chaplain • Intake staff ment in conjunction with a gap analysis of current prac-
• Chief executive • Language services tices, using resources such as the recommendations of the
officer coordinator
• Chief medical officer • Medical staff
HLC Report of Findings and the National Standards for

• Chief nursing officer • Nursing staff

Culturally and Linguistically Appropriate Services (CLAS).

• Chief operating • Patient advocates

officer • Patient safety officer
As health care organizations plan for new C&L practices,

• Community members • Patients and families

it is important that they understand the desires and needs

• Dietary services • Quality improvement

of their staff. Consideration for the preferences of the staff
• Diversity officer officer
who utilize these services is one way to encourage the
• Financial assistance/ • Recruiter
effective implementation of new practices. In addition,
billing staff • Risk management
new services should be easy to use and impose minimal
• Human resources officer delay to care and treatment [35].
director • Social services
• Information • Staff/clinical educator This report does not provide a step-by-step guide to
technology staff becoming culturally competent. The road map to cul-
tural competence is unique for each organization, and
there is no “one size fits all” solution. As shown by HLC
Beyond Self-Assessment study hospitals, motivators and journeys toward cultural
Self-assessment should be a continuous process. Once an competence are distinct. It is our hope that this report
organization has explored the practices that it has in place can help organizations tailor their initiatives to meet the
to meet C&L needs, these practices should be monitored unique needs of their diverse patient populations.
and evaluated. The HLC study found that some hospitals
46
developed practices to meet specific C&L needs, but
sometimes they did not achieve the desired results. For
example, a hospital may have a contract with a telephone
CHAPTER 8: Tailoring Initiatives to Meet the Needs of Diverse Populations:
A Self-Assessment Tool

Self-Assessment Tool
We provide this self-assessment tool to help organizations evaluate the way they currently provide care
and services to diverse patient populations. The tool is intended to address the main issues that emerged
from the Hospitals, Language, and Culture (HLC) study, and the questions are designed to promote dis-
cussion around the need to improve or expand current initiatives to meet patients’ cultural and language
(C&L) needs. The questions are organized by four key themes: Building a Foundation, Collecting and
Using Data to Improve Services, Accommodating the Needs of Specific Populations, and Establishing
Internal and External Collaborations.

Building a Foundation
Developing a Supportive Infrastructure for Cultural Competence
1. How does our leadership currently support the provision of culturally competent care?
2. In what ways does our mission statement or other guiding principles (e.g., vision, values) reflect an organizational
commitment to providing culturally competent care?
3. How have we operationalized our commitment to the provision of culturally competent care into organizational
actions, procedures, services, and resources?
• How do our C&L services reflect an understanding of the needs of the population?
• What resources (e.g., financial, staff ) have we dedicated to C&L activities?
o Which internal resources have been identified to support C&L activities and improve patient-provider
communication?
o Which external resources have been explored to provide or pay for C&L activities and improve patient-
provider communication?
4. In what ways have we used the National Standards for Culturally and Linguistically Appropriate Services
(CLAS) or other guidance47 to incorporate cultural competence into organizational planning?
5. Which organizational policies and procedures, if any, set expectations for staff for providing culturally and
linguistically appropriate care?
• Do we have policies and/or procedures that address the following:
o Reinforcing the importance of cultural sensitivity and effective communication in the provision of care
o Supporting the use of professional health care interpreters
o Discouraging the use of family, minors, or other untrained individuals as interpreters
o Suggesting which types of language services are appropriate for certain situations (e.g., on-site, telephone, video)
o Requiring the use of language services throughout the continuum of care
o Resolving or mediating any cross-cultural conflicts that may arise
• What training have staff received regarding these policies and procedures and how to abide by them?
• How is compliance with these policies and procedures monitored?

Integrating Culture and Language into Organizational Systems

6. Which of our organizational goals support staff diversity?

47
• What are our strategies for staff recruitment?
• What are our strategies for staff retention?

47 Other guidance may include the United States Department of Justice’s Language Assistance Self-Assessment and Planning Tool for Recipients of Federal Financial
Assistance [36], United States Department of Health and Human Services’ Patient-Centered Guide to Implementing Language Access Services in Healthcare
Organizations [37], and the American College of Healthcare Executive, American Hospital Association, Institute for Diversity in Health Management, and
National Center for Healthcare Leadership’s Strategies for Leadership: Does Your Hospital Reflect the Community It Serves, A Diversity and Cultural Proficiency
Assessment Tool for Leaders [38].
 CHAPTER 8: Tailoring Initiatives to Meet the Needs of Diverse Populations:
A Self-Assessment Tool

7. Which members of our organization are responsible for coordinating C&L initiatives?
• In what ways does leadership support those in charge of C&L initiatives?
8. Is there a dedicated staff position for coordinating C&L initiatives?
o What are the position’s specific responsibilities?
o Does this position report to an executive in the organization?
• Is there a high-level task force that coordinates C&L initiatives?
o Who serves on the task force?
o How many members are internal or external to the organization?
o Are there a range of staff levels and disciplines represented?
o How often does the task force meet?
o How does the task force review policies and procedures to ensure they address the diverse needs of patients
and staff?
o How does the task force support efforts for ongoing cultural competence training for staff at all levels?
o What is the process for implementing task force recommendations?
9. What types of financial systems are in place to remove barriers to using C&L services?
• How do we budget funds for the provision of culturally appropriate services?
o How do we budget funds for the provision of language services?
o Can we manage costs by cancelling/rescheduling interpreter appointments when patients cancel/reschedule
appointments?

Integrating Cultural Competence into Patient Care

10. Are we effectively using staff across disciplines to provide culturally and linguistically appropriate care?
11. What formal systems do we have for identifying patients’ C&L needs?
• Have we determined the first points of contact at which C&L needs are best identified?
• How do staff handle phone calls from patients with language needs?
• How does the phone system handle calls from patients with language needs (e.g., automated system, operator)
• How do we ensure that information regarding C&L needs follows the patient throughout the continuum
of care?
12. What tools are provided to staff to determine the appropriate language services?
• What resources are available to identify language needs (e.g., “I Speak” cards, telephone interpreting services)?
• What training have staff received to understand and use the resources available to identify language needs?
13. What tools and resources are available to staff to help them meet patients’ cultural needs?
• How are staff made aware of these tools?
• What type of training have staff received to help them meet the unique cultural needs of the patient
population?
14. How are staff made aware of the availability of C&L services?
• Are interpreter services incorporated at the patient care level to ensure visibility?
• What type of training have staff received regarding the appropriate use of C&L services?
15. What type of training have staff received regarding how to access C&L services?
48
• Are staff aware of the regulatory requirements, mandates, and national standards regarding the provision of
language services?
• What internal materials are available on how to access C&L services during hours, after-hours, and for
certain departments (e.g., the emergency room)?
• How are C&L services accessed (e.g., on-site interpreters, contract interpreters, telephone or video
language services, chaplain, religious and spiritual services, dietary services, etc.)?
CHAPTER 8: Tailoring Initiatives to Meet the Needs of Diverse Populations:
A Self-Assessment Tool

16. What type of training is required for those providing language services?
• If using staff to interpret:
o Is there a policy that ensures staff are proficient in English and the target language, including relevant
medical terminology?
o Is there a policy that ensures staff understand the role of the interpreter, Health Insurance Portability
and Accountability Act (HIPAA) and confidentiality issues, and interpreter codes of ethics and
standards of practice?
o Are there requirements for ongoing testing and training?
o Have guidelines been developed for dual-role interpreters?
• If using an outside vendor for language services:
o Are there standards for training and competency that agency interpreters have to meet?
o Does the hospital ensure that outside vendors comply with hospital policies and procedures related to
such issues as language proficiency, the role of interpreters, HIPAA, confidentiality, ethics, and standards
of practice?
o How do we ensure that contract interpreters are meeting those standards?
17. What types of written materials (e.g., informed consent, medication information, discharge instructions) does
our organization create or have translated into patients’ primary languages?
• Are professional translators used to translate materials?
• Is there a formal quality review process for these materials?
• Is there a central repository for translated documents to minimize duplication and control the quality of
the documents?
• How are health literacy and cultural issues addressed by written materials?
• Are other options available for patients with low literacy or low health literacy skills (e.g., video or audio
instructions)?
• What is the process for tracking print materials for revisions and updates?

Collecting and Using Data to Improve Services

Assessing the Need for C&L Services
18. How have we assessed the C&L needs of the community?
• What type of community-level demographic data do we collect (e.g., age, gender, race/ethnicity, primary
spoken and/or written language, socioeconomic status, religion, health literacy level, etc.)?
o How often are these data collected?
o Are these data self-reported?
o Do staff in all departments/care units have access are these data?
• What methods do we use to collect data from the community?
o Have we conducted individual interviews and/or focus groups with community leaders, patients, and
local businesses?
o Are there other data regarding community demographics that we can access?
19. How have we assessed the C&L needs of our patients?
• What type of patient-level demographic data do we collect (e.g., age, gender, race/ethnicity, primary 49
spoken and/or written language, religion, sexual orientation, disabilities, cultural needs, dietary needs,
health literacy level, etc.)?
• How do we ensure the accuracy of the data?
o Do we collect data directly from our patients?
 CHAPTER 8: Tailoring Initiatives to Meet the Needs of Diverse Populations:
A Self-Assessment Tool

o Are staff trained on the best way to obtain data in a manner that is respectful to the patient and com-
fortable for the staff?
o Has the organization utilized tools such as the Health Research and Educational Trust (HRET) Toolkit
for collecting data on race, ethnicity, and primary language to aid their data collection efforts?
• What are our policies and/or procedures that address the systematic collection of data?
20. How are these data used to create C&L initiatives?

Monitoring C&L Service Utilization

21. How are cultural issues incorporated into patient care?
• How often do cultural issues have an impact on patient care?
• Do staff consider religious and spiritual beliefs, cultural beliefs, folk remedies, traditions, rituals, and
alternative medicine when providing care?
• What skills do staff have to explore patients’ perspectives including cultural and religious beliefs related to
health, illness, and treatment?
• Do staff document situations in which cultural issues arise?
o Do chaplains record encounters with patients?
o Are dietary considerations regarding culture and/or religion recorded?
22. How are language issues incorporated into patient care?
• Is there formal documentation of interpreter encounters?
o Where is the encounter documented (e.g., interpreter log, patient’s medical record)?
o Is the type of interpreter documented (e.g., on-site, telephone, video)?
o Is there a policy for documenting interpreter encounters?
o Are staff educated on the importance of documenting interpreter encounters?
• Are encounters documented when an interpreter has been offered but has been refused by a patient?
o Is there a policy for documenting the refusal of interpreter services?
o Are staff educated on the importance of documenting the refusal of interpreter services?
• Are the different forms of interpreters (e.g., on-site, telephone, video) evaluated for efficiency, cost, and quality?
23. How are data regarding the use of C&L services reviewed and compared to the C&L needs identified
through demographic data collection?

Using Data to Improve C&L Services

24. What is the baseline for the C&L services we currently provide?
• Can we use this baseline to compare our progress as we improve C&L services?
25. How do we measure the quality of our C&L services?
• What systems are in place to collect feedback from patients and staff?
• Are we asking the right questions to obtain information regarding the care we provide to patients with
C&L needs?
• How do we obtain feedback from patients with language needs?
o Do patient satisfaction surveys include questions about C&L services?
50
o Is there a mechanism in place to translate written surveys and patient responses?
o Are focus groups and patient interviews used to obtain patient satisfaction data?
• Are our patients satisfied with the communication services, resources, and tools provided to them?
• How are these data used to improve C&L services?
CHAPTER 8: Tailoring Initiatives to Meet the Needs of Diverse Populations:
A Self-Assessment Tool

26. How are data used to identify disparities in health care and improve C&L services?
• Are data regarding outcomes, performance and quality indicators, adverse events, etc., stratified by
demographic variables?
• Which demographic variables are used to stratify data?
• Is there an information system in place to link demographic data to other information to facilitate analysis?
• Are these results used to improve the C&L services provided for diverse populations?

Accommodating the Needs of Specific Populations

Promoting Staff Awareness through Training, Dialogue, and Support
27. How does staff training address the importance of effective communication in the provision of care?
• Does training address the roles that language, literacy, and culture play?
• Are these issues addressed during orientation and ongoing training?
• Are staff provided training on how to access available resources to meet the C&L needs of patients?
o Are they trained to access on-site interpreters, telephone, or video interpreters?
• What type of training have staff received on how to work with interpreters?
28. How are staff educated on the unique C&L needs of the patients served?
• Do staff receive cultural competence training?
o When does training occur?
o Is the training required or optional?
o How often is training provided (e.g., during orientation, annually to all staff )?
o What issues are addressed in the training?
o Who provides the training?
29. What educational materials and tools are staff provided regarding the C&L issues of the service community?
• Are there any online applications or intranet resources that provide cross-cultural information?
• Do staff have an opportunity to dialogue about the cultures and languages encountered?
• Are staff required to demonstrate competency regarding the use of C&L resources and tools?
30. How can technology enhance or better facilitate existing language services?
• Are staff trained to properly use telephone or video medical interpreting services?
• Is the appropriate equipment present in patient rooms (e.g., speakerphone, dual handset telephones,
video equipment)?
• Are speech output devices and/or bilingual communication boards made available to supplement
language services?

Creating an Environment that Meets Specific Patient Needs

31. What aspects of the physical environment have been evaluated to determine whether they meet specific
patient needs?
• Is signage readable, in appropriate languages, and available throughout the organization?
• Is it easy for patients to identify and access the organization’s entry points?
32. What changes have we made to the physical environment that support patient diversity?
• Are there rooms available for special patient needs such as prayer, family conferences, and individual 51
consultations?
• Do we have patient rights and responsibilities documents translated into our most dominant languages
and posted in clear view of all major entry points?
• Have we considered ways to accommodate patients with large families?
 CHAPTER 8: Tailoring Initiatives to Meet the Needs of Diverse Populations:
A Self-Assessment Tool

33. How have we adapted our patient care services to incorporate cultural beliefs?
• Is there a need to modify visitation hours to accommodate patient needs?
• How can we adjust our policies and procedures to accommodate cultural considerations?
• Do our dietary menus reflect our commitment to diversity and culturally competent care?

Helping Patients Manage Their Care

34. What programs do we have that help patients understand and navigate the health care system?
• Do we have educational resources that explain the health care system?
• What mechanism is in place for patients to ask questions about the health care system?
• Are staff available to assist patients with insurance, payment, and logistical issues?
35. What types of patient education and training do we provide that help patients make informed decisions
and actively participate in their care?
• Does our in-house pharmacy translate prescription and warning labels into the most common patient
languages?
• Do discharge instructions take into account such factors as a patient’s language, health literacy, cultural
beliefs, access, child care, family support, etc.?
• How can technology be used as a tool to provide patient education?
o Are electronically translated patient education materials assessed for accuracy?
• Are patients given an opportunity to ask questions regarding their instructions?
• How are patients assessed for comprehension of their instructions (e.g., asked questions, teach-back processes)?

Establishing Centralized Programs that Meet Specific Needs of Large Populations

36. What culturally centered programs have been developed to address the needs of our larger populations?
• Are there any current programs that could be more culturally focused?
37. What programs have been built around religious and spiritual beliefs?
• Is our chaplaincy service diverse and inclusive of multiple religions?

Establishing Internal and External Collaborations

Working Together within the Hospital
38. How are activities and initiatives related to culturally competent care being coordinated within our organization?
• How are we involving different stakeholders from across the organization to collaborate in C&L efforts?
o Committees may consist of:
o Staff (clinical and administrative leadership, nursing, medical staff, pastoral care, interpreting services,
social work, human resources, patient safety/risk management, quality improvement staff, cultural
brokers, community outreach/marketing, etc.)
o Patients
o Community leaders
o Religious leaders
• Do stakeholders represent varying perspectives within the organization (including various departments,
52
positions, professional levels)?
• Do stakeholders represent the varying perspectives within the community (e.g., cultures, religions)?
• What activities are stakeholders overseeing?
o How are these C&L activities being centrally coordinated?
• How are stakeholders addressing patient and/or staff concerns related to C&L issues?
CHAPTER 8: Tailoring Initiatives to Meet the Needs of Diverse Populations:
A Self-Assessment Tool

Building Bridges with Other Hospitals

39. What existing resources can we share with other organizations or local, state, and national associations?
• Are there best practices related to implementing culturally competent care that we could share with other
organizations?
• Are there any lessons learned from implementing culturally competent care that would be useful to share with
other organizations?
• What types of information would we like to learn from other organizations?
• What resources are available that other organizations can share with us?
• What organizations or types of organizations do we want to share information or resources with?
40. What resources or materials do we want to develop in collaboration with other organizations?
• Are there specific types of resources we want to develop with other organizations (e.g., a multi-hospital
interpreter network, educational resources, or translations of vital documents such as consent forms,
complaint forms, patient rights information, intake forms, etc.)
• Which languages should we target?
• Which hospitals or other health care organizations should we collaborate with?

Engaging the Community

41. How many community representatives are involved in our C&L-related committees?
• On what other committees would having community representatives be helpful?
• Do the community representatives currently involved provide perspectives of the diverse needs of
the populations we serve?
42. What opportunities have we identified to partner with educational institutions to recruit and train a diverse
workforce?
• What opportunities are available for training current staff?
• What types of recruitment opportunities are available in the surrounding community?
• What incentives are we providing to recruit and train a diverse, bilingual staff?
• Are there opportunities for developing a future diverse workforce?
43. Which community resources exist that could help us better meet C&L needs?
• What community organizations or networks can we collaborate with to help bridge cultural barriers?
• What religious leaders or chaplains have we developed relationships with to meet patient needs?
• Are there traditional healers within the community to whom we can reach out?
• How have we trained staff to be aware of and access these external resources?
44. How have we reached out to the community and/or facilitated access to both internal and external services?
• Are patients aware of the community programs or services available that relate to patients’ continuum of care?
• Are there public assistance programs that we could help patients become more aware of as part of their
overall care?
• What adult learning programs could we partner with to help with issues of health literacy?

53
 Appendix A: Endnotes
1. Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
Washington, DC: National Academy Press; 2002.

2. Hasnain-Wynia R, Yonek J, Pierce D, Kang R, Greising CH. Hospital Language Services for Patients with
Limited English Proficiency: Results from a National Survey. Chicago, IL: Health Research & Educational Trust
and the National Health Law Program; 2006.

3. Wilson-Stronks A, Galvez, E. Hospitals, Language, and Culture: A Snapshot of the Nation Exploring Cultural and
Linguistic Services in the Nation’s Hospitals A Report of Findings. Oakbrook Terrace: The Joint Commission; 2007.

4. Brashers DH, Stephen M, Neidig JL. The Patient Self-Advocacy Scale: Measuring patient involvement in
health care decision-making interactions. Health Commun. 1999:97-121.

5. Marelich WD, Murphy, DA. Effects of empowerment among HIV-positive women on the patient-provider
relationship. AIDS CARE. 2003;15:475-481.

6. Flores G, Laws MB, Mayo SJ, Zuckerman B, Abreu M, Medina L, Hardt EJ. Errors in medical interpretation
and their potential clinical consequences in pediatric encounters. Pediatrics. Jan 2003;111(1):6-14.

7. Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study.
Int J Qual Health Care. Apr 2007;19(2):60-67.

8. The Joint Commission. Root Causes of Sentinel Events 2006. Available at: http://www.jointcommission.org/NR/
rdonlyres/FA465646-5F5F-4543-AC8F-E8AF6571E372/0/root_cause_se.jpg. Accessed February 19, 2008.

9. Woolf SH, Kuzel AJ, Dovey SM, Phillips RL Jr. A string of mistakes: the importance of cascade analysis in
describing, counting, and preventing medical errors. Ann Fam Med. Jul-Aug 2004;2(4):317-326.

10. Jacobs EA, Shepard DS, Suaya JA, Stone EL. Overcoming language barriers in health care: costs and benefits
of interpreter services. Am J Public Health. May 2004;94(5):866-869.

11. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with
limited English proficiency? A systematic review of the literature. Health Serv Res. Apr 2007;42(2):727-754.

12. Brach C, Fraser I. Reducing disparities through culturally competent health care: an analysis of the business
case. Qual Manag Health Care. Summer 2002;10(4):15-28.

13. Schyve PM. Language differences as a barrier to quality and safety in health care: The Joint Commission per-
spective. J Gen Intern Med. 2007 Nov;22 Suppl 2:360-1.

14. American Medical Association, The Ethical Force Program. Improving Communication — Improving Care:
How Health Care Organizations can Ensure Effective, Patient-Centered Communication with People from Diverse
Populations. Chicago, IL: Ethical Force Program, American Medical Association; 2006.
54
15. United States Department of Health and Human Services, Office of Minority Health. National Standards
for Culturally and Linguistically Appropriate Services in Health Care. Washington, DC: HHS; 2001.

16. The Joint Commission. What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety.
Oakbrook Terrace, IL: The Joint Commission; 2007.
Appendix A: Endnotes

17. Adapted from Cross et al., 1998 and US Department of Health and Human Services, Office of Minority
Health, 2000. Available at: www.ahrq.gov/about/cods/cultcompdef.htm. Accessed December 19, 2006.

18. National Council on Interpreting in Health Care. The Terminology of Health Care Interpreting: A Glossary
of Terms. Washington, DC: National Council on Interpreting in Health Care; 2001. Available at:
www.hablamosjuntos.org/pdf_files/TheTerminologyofHealthCareInterpreting.pdf. Accessed
on February 19, 2008.

19. Jacobson KL, Gazmararian JA, Kripalani S, McMorris KJ, Blake SC, Brach C. Is Our Pharmacy Meeting
Patients’ Needs? A Pharmacy Health Literacy Assessment Tool User’s Guide. (Prepared under contract
No. 290-00-0011 T07) AHRQ Publication No. 07-0051. Rockville, MD: Agency for Healthcare
Research and Quality; October 2007.

20. United States Department of Health and Human Services, Office for Civil Rights. Guidance to Federal
Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting
Limited English Proficient Persons. Washington, DC: HHS;2003:68 Fed. Reg. At 47311-47323.

21. Paras M. Straight Talk: Model Hospital Policies and Procedures on Language Access. Oakland, CA: California
Health Care Safety Net Institute; 2005.

22. Georgetown National Center for Cultural Competence. Cultural and Linguistic Competence Policy Assessment.
Available at: www.clcpa.info/. Accessed February 21, 2008.

23. University of Kansas, Work Group for Community Health and Development. Conducting Concerns Surveys.
Available at: ctb.ku.edu/en/tablecontents/section_1045.htm. Accessed February 19, 2008.

24. Executive Office of the President, Office of Management and Budget (OMB), Office of Information and
Regulatory Affairs. Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity,
Federal Register Notice. Washington, DC: Executive Office of the President; October 30, 1997. Available at:
www.whitehouse.gov/omb/fedreg/1997standards.html. Accessed February 19, 2008.

25. Hasnain-Wynia R, Pierce D, Haque A, Hedges Greising C, Prince V, Reiter J. Health Research and
Educational Trust Disparities Toolkit. Chicago, IL: Health Research & Educational Trust; 2007. Available
at: www.hretdisparities.org. Accessed February 19, 2008.

26. United States Department of Health and Human Services, Health Resources and Services Administration.
Unified Health Communication 101: Addressing Health Literacy, Cultural Competency, and Limited English
Proficiency. Available at: www.hrsa.gov/healthliteracy/training.htm. Accessed on February 22, 2008.

27. United States Department of Health and Human Services, Office of Minority Health. A Physician’s Practical Guide
to Culturally Competent Care. Available at: cccm.thinkculturalhealth.org/. Accessed on February 22, 2008.

55
28. Kelly N. Telephone interpreting in health care settings: some commonly asked questions. The ATA
Chronicle. June 2007. Available at: www.atanet.org/chronicle/feature_article_june2007.php.
Accessed on February 19, 2008.

29. Freeman HP, Muth BJ, Kerner JF. Expanding access to cancer screening and clinical follow-up among the
medically underserved. Cancer Pract. 1995;3:19-30.
 Appendix A: Endnotes

30. Freeman HP. A model patient navigation program. Oncol Issues. 2004 Sept/Oct;19:44-46.

31. Central Nebraska – Area Health Education Center, Inc., Hablamos Juntos. Developing a Medical Interpreting
Training Program. Fresno, CA: Hablamos Juntos; 2005. Available at: www.hablamosjuntos.org/
resource_guide_portal/pdf/13Training_Program-CNAHEC.pdf. Accessed February 19, 2008.

32. Hablamos Juntos. Educational Partnerships for Interpreter Training: An Hablamos Juntos Initiative. Fresno, CA:
Hablamos Juntos; 2005. Available at: www.hablamosjuntos.org/resource_guide_portal/pdf/
12Training_Program_Profile_091405.pdf. Accessed February 19, 2008.

33. National Linguistic & Cultural Programs (NLCP), Kaiser Permanente. Health Care Interpreter Certificate
Program [webpage]. Available at: www.kphci.org/. Accessed February 19, 2008.

34. National Center for Cultural Competence. Sharing a Legacy of Caring: Partnerships Between Health Care and
Faith-Based Organizations. Washington, DC: Georgetown University Child Development Center; 2001.

35. Regenstein M. Measuring and improving the quality of hospital language services: insight from the Speaking
Together collaborative. J Gen Intern Med. 2007; 22(Suppl 2):356-9.

36. United States Department of Justice, Coordination and Review Section, Civil Rights Division. Language
Assistance Self-Assessment and Planning Tool for Recipients of Federal Financial Assistance. Washington, DC:
DOJ. Available at: www.lep.gov/selfassesstool.htm. Accessed February 19, 2008.

37. United States Department of Health and Human Services, Office of Minority Health. A Patient-Centered Guide
to Implementing Language Access Services in Healthcare Organizations. Washington, DC: HHS; 2005. 1-253.

38. American College of Healthcare Executives, American Hospital Association, Institute for Diversity in Health
Management, National Center for Healthcare Leadership. Does Your Hospital Reflect the Community it Serves?:
A Diversity and Cultural Proficiency Assessment Tool for Leaders. Chicago, IL: American Hospital Association; April
2004. Available at: www.aha.org/aha/content/2004/pdf/diversitytool.pdf. Accessed February 19, 2008.

39. Adapted from Cross T, Bazron B, Dennis K, Isaacs M. Towards a Culturally Competent System of Care (Volume
I). Georgetown University Center for Child and Human Development, Washington, DC; 1989. Available at:
https://www.omhrc.gov/templates/browse.aspx?1v1=2&lv1ID=107. Accessed December 12, 2006.

40. Jezewski MA. Cultural brokering in migrant farm worker health care. West J Nurs Res. 1990 Aug;12(4):497-513.
Jezewski MA, Sotnik P. Culture Brokering: Providing Culturally Competent Rehabilitation Services to Foreign-born
Persons. Buffalo, New York; 2001.

41. Adapted from Bridging the Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker Programs.
Developed for the National Health Service Corps Bureau of Health Professions, Health Resources and Services
Administration, U.S. Department of Health and Human Services by National Center for Cultural Competence,

56
Georgetown University Center for Child and Human Development. Spring/Summer 2004.

42. Adapted from Sampson A. Language Services Resource Guide for Health Care Providers. The National Health
Law Program and the National Council on Interpreting in Health Care. October 2006.

43. The Joint Commission. The Joint Commission Standards for Hospitals. Oakbrook Terrace, IL: The Joint
Commission; 2008.
APPENDIX B: Glossary
bilingual staff: for the purposes of this report, we have disparities: racial and ethnic differences in health care
used this term to refer to individuals who have some that are not attributable to other known factors [1].
degree of proficiency in more than one language.
Bilingual staff includes those who serve in a dual role, doula: an individual who assists with labor and after
providing interpreter services for the hospital in addition childbirth.
to their primary position.
effective communication: a critical component to the
competence: having the capacity to function effectively patient’s understanding of the informed consent process,
as an individual and an organization within the context participation in his or her care, understanding of all
of the cultural beliefs, behaviors, and needs presented by information provided to him or her, and ability to fulfill
people and their communities [39]. the responsibilities related to his or her care. In order for
communication to be effective, the information provided
cultural broker: an individual who bridges, links, or must be complete, accurate, timely, unambiguous, and
mediates between groups or persons of differing cultural understood by the patient.
backgrounds for the purpose of reducing conflicts, pro-
ducing change, or advocating on behalf of a cultural group halal: dietary laws which regulate the preparation of food
or person [40]. Cultural brokers can also be medical pro- in accordance with Muslim principles and techniques.
fessionals who draw upon cultural and health science
knowledge and skills to negotiate with the patient and Imam: a Muslim religious leader; prayer leader of a mosque.
health system toward an effective outcome [41].
interpreter/interpretation/interpreting: an interpreter is
cultural competence: the ability of health care providers a person who renders a message spoken/signed in one lan-
and health care organizations to understand and respond guage into one or more languages. The practice of inter-
effectively to the cultural and language needs brought by preting is distinguished in this report from translating to
the patient to the health care encounter. Cultural compe- include only spoken/signed language. Interpreting refers to
tence requires organizations and their personnel to: 1) value the process of interpretation; interpreter refers to the person
diversity; 2) assess themselves; 3) manage the dynamics of who is providing the interpretation [42].
difference; 4) acquire and institutionalize cultural knowl-
edge; and 5) adapt to diversity and the cultural contexts of language services: for purposes of this report, language
individuals and communities served [17]. services refers to those mechanisms used to facilitate com-
munication with individuals who do not speak English and
culturally and linguistically appropriate services: those who are deaf or hard of hearing. These services can
health care services that are respectful of and responsive include in-person interpretation using a professional health
to cultural and language needs [15]. care interpreter, bilingual staff, or remote interpreting sys-
tems such as telephone or video medical interpreting.
culture: integrated patterns of human behavior that Language services also refer to processes in place to provide
include the language, thoughts, communications, translation of written materials or signage.
actions, customs, beliefs, values, and institutions of racial,
ethnic, religious, or social groups [39]. limited English proficiency (LEP): a legal concept
referring to a level of English proficiency that is insuffi- 57
curandero: a traditional folk healer in some Latin cient to ensure equal access to public services without an
American cultures dedicated to curing physical and/or interpreter; the inability to speak, read, write, or under-
spiritual illnesses. stand English at a level that permits an individual to
interact effectively with health care providers or social
service agencies [20].
 APPENDIX B: Glossary

National Standards on Culturally and Linguistically translator/translation/translating: a translator is a per-

Appropriate Services (CLAS standards): the collective son who converts written text in one language into another
set of culturally and linguistically appropriate services language. Translation is distinguished from interpretation
(CLAS) mandates, guidelines, and recommendations to refer to written language [42].
issued by the United States Department of Health and
Human Services Office of Minority Health intended to video medical interpreting: interpreting carried out
inform, guide, and facilitate required and recommended remotely using a video camera that enables an interpreter
practices related to culturally and linguistically appropriate in a remote location to both see and hear the parties for
health services [15]. whom he or she is interpreting via a television monitor.
The interpretation is relayed to the principal parties by
professional health care interpreter: an individual with speakerphone or through headsets. Two-way interactive
the appropriate training and experience to interpret with television can also be used so that the other parties can
consistency and accuracy and who adheres to a code of interact with the interpreter as though face-to-face [18].
professional ethics [18].

sentinel event: an unexpected occurrence involving

death or serious physical or psychological injury, or the
risk thereof. Serious injury specifically includes loss of
limb or function. The phrase or the risk thereof includes
any process variation for which a recurrence would carry
a significant chance of a serious adverse outcome [43].

shaman: a member of certain tribal societies who acts as

a medium between the natural and supernatural world.

telephone interpreting: interpreting carried out

remotely, with the interpreter connected by telephone to
the principal parties, typically provided through speaker-
phones or headsets. In health care settings, the principal
parties (e.g., doctor and patient) are normally in the same
room, but telephone interpreting can be used to serve
individuals who are also connected to each other only by
telephone [18].

58
 For more information about the Hospitals, Language, and Culture study, please visit
www.jointcommission.org/PatientSafety/HLC/ or email [email protected].