texas woman’s university -...

HSM5003 Field Research Red Group 1

Running Head: FIELD RESEARCH PROJECT LINGUISTIC SERVICES

Field Research Project:

The Role of Hospital Management in the Provision of Linguistic Services

Red Group: Jeri Hargrave, Robin Henson, Michael Lopez, and Connie Martinez

July 22, 2009

HSM 5003 Management of Health Service Organizations

Texas Woman’s University


The Role of Upper Hospital Management in Providing Linguistic Services

Introduction

In 2008, 15% of the United States (U.S.) population, or approximately 45.5 million, was

comprised of Hispanic individuals. The percentage of Hispanics is forecasted to steadily

increase, and by 2050 the U.S. will be composed of a minority-majority, with non-Hispanic

whites becoming the minority (United States Census Bureau [USCB], 2008). As the U.S. adjusts

to this shift in demographics, the differences between culture and language intensify. This

enlarging gap is evident in our nation’s hospitals as healthcare organizations are unable to keep

up with cultural and language needs of this rapidly growing population. Cultural disparities exist

and have severe implications for patients, individuals and healthcare organizations (LaVeist,

Richardson, Relosa & Sawaya, 2008; Reynolds, 2004).

Purpose

Healthcare management must develop strategies that promote respect for cultural

differences and provide language support for their patients and employees within the healthcare

organizations (Reynolds, 2004). On June 19, 2009, Governor Rick Perry signed a bill that

establishes a committee to oversee Healthcare Interpreter Qualifications in the state of Texas

(Green, 2009). This bill is an important step because 38% of the U.S. Hispanic population

resides in Texas (Kaiser Family Foundation, 2008). This effort is one of many attempts that state

and local governments are making to close the gap between healthcare communication and

patients living in the U.S. with limited English proficiency (LEP) individuals. The purpose of

this field research project is to answer the question, “What is hospital management doing to

assure accurate translation of language for their Hispanic clientele?”


Justification

When healthcare organizations do not effectively address language competencies,

negative patient, staff, and organizational outcomes can occur (Schenker, Wang, Selig, Ng &

Fernandez, 2007). Overall patient safety is compromised when hospital staff and the patient are

unable to communicate. Language barriers cause erroneous patient histories that often lead to

inaccurate diagnoses and treatments. Approximately 31 errors per patient occur when untrained

staff and families are used to interpret (Green, 2009). Patient education, discharge instructions,

and medication adherence are impeded when forms and labels are not translated. The various

degrees and combinations of these components prolong the patient length of stay, encourage

return hospital visits, and spend billions of excess healthcare dollars (Bethell et al., 2006; Jacobs,

Sadowski, & Rathouz, 2007; Reynolds, 2004).

Besides compromising patient care safety, language barriers result in hospital staffing

problems. Accessing translational services is a time consuming process, causing staff to often

avoid formal linguistic services. Instead there is an over-reliance on accessible bilingual hospital

unit staff to translate for them resulting in excess time burden on the bilingual staff and the

potential for translation inaccuracies. These factors combined with the employee’s fear of

liability contribute to staff dissatisfaction and high turn over rates (Jacobs et al., 2007).

In addition to patient and staff concerns, language barriers pose serious problems on the

organizational level. Paying additional staff and telephone language translation places an

additional cost burden on the hospital, and it is inconclusive whether these services result in

decreased organizational costs. The lack of state and federal regulations make it harder for

hospital administrators to justify the added costs; however, the organization must consider that

failure to provide patient interpretation can incur liability and undue patient harm. Failure for a


healthcare organization to address cultural and language competence negatively influences the

perceptions of the general public and third party payers (LaViest et al., 2008).

Definition of Terms

1. Hispanic: “Hispanic individuals living in the United States include Cuban, Puerto Rican,

South or Central America, or other Spanish cultures of origin regardless of race” (USCB,

2008).

2. Limited English Proficiency (LEP): “ The inability to speak, read, write, or understand

English at a level that permits an individual to interact effectively with health care

providers or social service agencies” (Wilson-Stronks & Galvez, 2007, p.15).

3. Language competency: A process of effectively providing readily available, culturally

appropriate “oral and written language services to patients with LEP through such means

as bilingual/bicultural staff, trained medical interpreters, and qualified translators”

(Wilson-Stronks & Galvez, 2007, p.14).

4. Informal Linguistic Services: Utilization of patient services such as patient’s family

members, friends, as well as hospital staff to interpret and translate between two parties

that speak different languages (O’Leary, Federico, & Hampers, 2003).

5. Formal Linguistic Services: Utilization of individuals that have completed language

training programs, specific internship hours, and whose role is to specifically interpret

and translate between two parties that speak different languages. Usually handled by in-

house interpreters or can be outsourced and accessed through telecommunications

(Jacobs et al., 2007).


Literature Review

Language and Interpretation Services

Many times hospital staff rely on other hospital volunteers and family members for

translation. Several studies reveal that family members or volunteer interpreters are more likely

to misinterpret, omit or add information, or insert personal values into the translation. Using

family minors to translate complicated, private, and sensitive health information is not

uncommon (O’Leary et al., 2003).

Some hospital institutions utilize formal linguistic services. There are many

considerations that must be made when a hospital hires a formal language service. The

organization must determine: what services are available, how many languages are provided, the

quality of interpreter raining, and the level of advanced communication technology. The speed of

the service should also be investigated and experts recommend that the language service should

have a response time of 25 seconds. Moreover, staff usability should be a high priority

(Greenbaum, 2004). Finally, language services are costly. The estimated cost of formal

interpretation is $234 per Spanish speaking patient intervention (Jacobs et al., 2007).

Hospital Friendly Environment

It is imperative that the hospital environment display its cultural friendliness through the

provision of signage in different languages and through the use of pictures instead of words. The

pharmacy should provide multi-lingual prescriptions and each unit should have the capability to

provide hospital brochures and patient discharge teaching in a variety of languages. Specific

units that have a greater influx of patients, such as the Emergency Room, should be provided

with a greater number of interpreters. Hospitals should also have a consistent and systematic

approach to collecting patient data for ethnicity, race, and primary language. This information


should be analyzed and drive interventions that will reduce health disparities among minorities

(Pearson et al., 2007; Reynolds, 2004).

Hospital Administration’s Role

Dreaschlin and Myers (2007) posit that hospital management should have systems in

place to respond to the rapidly emerging differences in the culture and language of their patient

population. The commitment to adopt language competency should be highly visible to the

patients and to the staff. An established centralized program is recommended to support

consistent language services. This centralized program becomes the hub that collaborates with

education and risk management in order to identify and address staff and patient needs. In

addition, written policies must be developed to describe the types of language services that are

available, how patient’s can access these services, and the role of staff if a patient refuses a

language service (Wilson-Stronks & Galvez, 2007).

Research supports the hiring of diversity in the hospital organization workforce.

Currently, 85-90% of healthcare workforce in the United States is composed of non-minority

individuals (O’Leary et al., 2003). Patient surveys report a high satisfaction rate when minority

patients share their same culture and language with healthcare providers and hospital staff. In

turn, these patients have higher rates of trust, compliance, and improved outcomes of care

(Dreaschlin & Myers, 2007). Besides encouraging a diverse workforce, hospital management

should create financial incentives that will attract highly qualified language interpreters. These

upfront costs are proposed to have future cost-saving benefits (LaVeist et al., 2008; Pearson et

al., 2007).


What is Actually Being Done in the U.S.?

The IOM and OMH

Together the Institute of Medicine (IOM) and Office of Minority Health (OMH) are

actively seeking ways to breakdown language barriers in U.S. healthcare. In a meta-analysis

conducted in 1999, Non-Hispanic whites were more likely than minorities to receive healthcare

services and necessary treatments for acute and chronic diseases, citing language as a major

contributing factor. Based on these findings, the IOM provides recommendations for healthcare

managers and system administrators to meet the objectives of providing high quality care to

minority populations. (Institute of Medicine [IOM], 2002). Through the IOM recommendations,

the OMH has established 14 national standards known as the Culturally and Linguistically

Appropriate Services (CLAS), which assures that cultural and language competence are

addressed throughout healthcare organizations. CLAS Standards 4-7 address the patient’s access

to language services and is a Federal requirements for all recipients of Federal funds, such as

Medicare (Appendix A). The provision of free language assistance, hospital signage, and written

instructions in the patient’s language are included in the standards (United States Department of

Health and Human Services [USDHHS], 2007).

Language Tools

There are various tools that a hospital can utilize to assess its cultural and language

competency. The Cultural Competency Assessment Tool for Hospitals (CCATH) is a free, 28-

item tool that assesses how well the hospital organization lines up with CLAS standards

(Dreaschlin & Myers, 2007). The Cultural Competency Organizational Assessment-360

(COA360) is a new tool developed to assess the cultural competency of organizations. The

COA360 is the first tool designed to assess organizations. Currently, only individuals are


assessed. Like the CCATH, the COA360 is designed in accordance with the CLAS Standards

and recommendations from the IOM (LaViest et al., 2008).

Hospital, Language, and Culture Study

Through a California Endowment, 60 hospitals that represented 32 states, were chosen to

participate in the Hospital, Language, and Culture (HLC) study. The HLC was conducted by

Joint Commission and consisted of a one-day site visit and a 26-question pre-visit questionnaire

presented to hospital management and administration, human resources and clinical staff. The

HLC focused on the cultural competency of the nation’s hospitals. Language and translation

services were a key domain that the HLC evaluated. A six-item Management and Administration

Questionnaire was presented to hospital management to assess the role of administration in

cultural and language competency (see Appendix B).

Of the hospitals in the HLC survey, only 60% had a designated cultural and linguistic

department. Ninety percent reported in the questionnaire that they had written policies in place,

however, during the on-site visit the majority were unable to produce written language policies.

The majority of the hospitals had some type of budget money allocated for linguistic services,

however, only 30% reported language and culture as a specific line item. Of those surveyed, 55%

of the sample had designated executive-level staff that was directly responsible for culture and

language. The study did not list the findings about the cultural representation reflected in their

governing bodies (see Table 1). Based on these findings, the HLC report recommends that

specific action should be taken regarding language and hospital management:

Consider establishing a centralized program with executive-level reporting that

coordinates language services


Hospital CEO’s and upper management should make their commitment to

linguistically appropriate care highly visible to staff and patients

Provision should be made for international multidisciplinary dialogues about

language issues to guide strategic planning

Financial incentives should be employed to recruit, develop, and retain qualified

healthcare interpreters

Future research to understand the motivating factors of hospital CEOs who

embrace linguistically appropriate care

The final comprehensive results of this study contributed to the development of the CLAS

national standards (Wilson-Stronks & Galvez, 2007, p. 8).

Methodology Criteria

For this project, the HLC Management and Administration Questionnaire was chosen.

This 6-item questionnaire assesses management’s role in addressing the linguistic needs of the

institution. The questionnaire was presented face-to-face or per telephone communication to

either the Cultural and Linguistic Service, QI, or Patient Safety departments within each hospital

(Wilson-Stronks & Galvez, 2007). See Appendix B for a listing of these questions.

Data Collection

This project utilized data from a convenience sample generated from five hospital

healthcare institutions: Atoka Memorial Hospital, Atoka, Oklahoma; Texas Hospital for

Advanced Medicine (formerly RHD) Dallas, Texas; Texas Health Presbyterian Hospital Denton,

Denton, Texas; Parkland Hospital, Dallas, Texas; Las Colinas Medical Center, Las Colinas,

Texas. Questionnaires were distributed to hospital administration, Patient Safety and Cultural

and Linguistic Service departments.


Data Results

The Management and Administration Questionnaire was administered to five area

hospitals. Results can be found in Table 1. Although 100% surveyed indicated that they had

Table 1

Management and Administration Questionnaire Results

Question Responses % HLC

Results %

1. Formal Plans Developed

Yes 5 100 77

No

2. Services Driven by Laws

Very strongly 4 80 90

Strongly 1 20 10

Somewhat

Not strongly

Not at all

n/a

3. Allocated Operating Funds

Yes, specific line item/dedicated budget 2 40 30

Yes, incorporated with another budget 2 40 40

No 1

20 20

4. Established Language Department

Yes 2 40 60

No 3

60 40

5. Executive Level Staff

Yes 3 60 55

No 2

40 45

6. Governing Board Members

Yes 1 20 N/A

No 4 80 N/A


strategic and formal business plans developed to meet the linguistic needs of their patient

population, only 40% of the organizations could physically locate these plans. Although the

majority of the hospitals (60%) do not have an established language service department, all but

one hospital stated that laws and regulations strongly influenced their provision of appropriate

linguistic services. Three of the five hospitals have a designated executive staff member assigned

to oversee linguistic competency plans and initiatives, including an executive vice-president, a

vice-president, and an individual that works directly under the CEO. Monies are allocated for

linguistic services in 80% of the institutions; however, only 2 are designated line items. Only one

hospital states its governing board adequately reflects the cultural diversity of the community in

which it serves.

As a side note, one of the five hospitals utilizes the In Touch ™ Critical Care Bed made

by Stryker. This bed was purchased by Texas Hospital for Advanced Medicine in May 2009.

The bed is able to verbalize pre-programmed questions and commands in 12 different languages.

It is not intuitive and it does not have the capacity to translate actual conversations between the

patient and the hospital staff. It is currently utilized in the Intensive Care Unit, and to some

degree, assists LEP patients with communication (see Appendix C).

Data Conclusion

The question, “What is hospital management doing to assure accurate translation of

language to their Hispanic clientele?” is not a simple one to answer. The research findings reveal

that hospital management perceives that they are taking a proactive role in managing the

language competency of their organization. The finding from this small convenient sample

reflect many similar findings from the HLC study (See Table 1). The five hospitals in this study

had a higher report of a formal language plan (100% vs. 77%), and executive level staff


managing the linguistic plans and initiatives (60% vs. 55%). The HLC sample had a higher

report of established language services (60% vs. 40%) and 90% were “very strongly” driven by

the law than the study sample (80%). Both samples reported that 80% had some form of

allocated funds for linguistic services. Each study contained small sample sizes, so caution must

be made when interpreting these results. The findings do reveal, however, that executive leaders

have an important role in initiating, directing, and integrating language competency into the

culture of their organizations.

Through incorporation of the recommendations from the HLC study, there are three

things that management must do to assure accurate linguistic competency within their

organization. The first is to establish a centralized cultural and language department with the

intention of meeting CLAS standards. This department can develop written policies and utilize

tools such as the CCATH and the COA360 to evaluate the linguistic competency of the

organization and guide future language endeavors. The organization must utilize the findings

from these tools to set performance goals and systematically evaluate progress towards achieving

these goals. Secondly, management must make their commitment visible. They can do this by

encouraging diversity on their governing boards and encouraging the hiring of diverse employees

in an effort to better reflect their community. In addition, they must create financial provisions in

the budget for translators, appropriate signage and brochures, and staff training. Finally,

healthcare management should study other executives who have successfully embraced linguistic

competency within their institutions in order to gain insight and knowledge for success

(Dreaschlin & Myers, 2007; LaViest et al., 2008; Wilson-Stronks & Galvez, 2007).


Appendix A

National Standards on Culturally and Linguistically Appropriate Services (CLAS)

Standards 4-7


National Standards on Culturally and Linguistically Appropriate Services (CLAS)

Standards 4-7

Standard 4

Health care organizations must offer and provide language assistant services, including bilingual

staff and interpreter services, at no cost to each patient/consumer with limited English

proficiency at all points of contact, in a timely manner during all hours of operation.

Standard 5

Health care organizations must provide to patients/consumers in their preferred language both

verbal offers and written notices informing them of their right to receive language services.

Standard 6

Health care organizations must assure the competence of language assistance provided to limited

English proficient patient/consumers by interpreters and bilingual staff. Family and friends

should not be used to provide interpretation services (except on request by the patient/consumer).

Standard 7

Healthcare organizations must make available easily understood patient-related materials and

post signage in the languages of the commonly encountered groups and/or groups represented in

the service areas.

(USDHHS, 2007)


Appendix B

Management and Administration Questionnaire

Hospitals, Language, and Culture use the Office of Minority Health (OMH) definition of

culturally competent healthcare: “services that are respectful of and responsive to the health

beliefs and practices, and cultural and linguistic needs of diverse patient populations.” For the

purposes of this project, “culture” refers primarily to characteristics of human behavior

associated with race, ethnicity, and religion. “Translation” refers to the conversion of spoken

communication from one language into another. Please answer the following questions honestly

based on your hospital’s services and administration. Remember, this is a baseline assessment

and there is no right or wrong answer.

1. Circle the correct answer; does the hospital specifically develop formal plans to meet the

cultural and linguistic needs of patients?

Cultural Needs Linguistic Needs Yes or No Yes or No

If yes, please check the types of plans that apply:

Strategic

Business

Budget

Other________________________________

Comments:

2. To what degree are your efforts to provide culturally and linguistically appropriate

services driven by laws and regulations?

Very strongly

Strongly

Somewhat

Not strongly

Not at all

Not applicable

Comments:

3. Does the hospital allocate operating funds for cultural and linguistic services?

Cultural Services

Yes, there is a specific line item or dedicated budget devoted to these services

Yes, but it is incorporated in another line item or budget


No

Linguistic Services

Yes, there is a specific line item or dedicated budget devoted to these services

Yes, but it is incorporated in another line item or budget

No

Comments:

4. Does the hospital have an established multicultural or language services department,

project, or office?

Yes

No

Comments:

5. Does the hospital have executive level staff with direct responsibility for managing

cultural and linguistic competency plans and initiatives?

Cultural Competency

Yes

No

Linguistic Competency

Yes

No

A. If yes, please list his/ her title(s):

Comments:

6. Is the patient population’s cultural and linguistic diversity part of the criteria for choosing

governing board members?

Cultural Diversity

Yes

No

Linguistic Diversity

Yes

No

Comments:


Appendix C

In Touch ™ Critical Care Bed


References

Bethell, C., Simpson, L., Read, D., Sobo, E.J., Vitucci, J., Latzke, B., et al. (2006). Quality and

safety of hospital care for children from Spanish-speaking families with limited

proficiency. Journal of Healthcare Quality: Promoting Excellence in Healthcare, 28(3),

3-16.

Dreaschlin, J.L., & Myers, V.L. (2007). A systems approach to culturally and linguistically

competent care. Journal of Healthcare Management, 52(4), 220-226.

Green, D. (2009). Texas Governor Rick Perry signs bill establishing a committee to oversee

health interpreter qualifications. Texas Association of Healthcare Interpreters and

Translators. Retrieved from http://www.pr.com/press-release/161004

Greenbaum, M.D. (2004). Selecting quality language services increases cultural competency.

Managed Healthcare Executive, 60.

Institute of Medicine. (2002 March). Unequal treatment: What healthcare system administrators

need to know about racial and ethnic disparities in healthcare: Report Brief. Unequal

Treatment: Confronting Racial and Ethnic Disparities in Health Care. Retrieved from

http://www.iom.edu/CMS/3704/4475/14973.aspx

Jacobs, E.A., Sadowski, L.S., & Rathouz, P.J. (2007). The impact of an enhanced interpreter

service intervention on hospital costs and patient satisfaction. Journal of General Internal

Medicine, 22, 306-311.

Kaiser Family Foundation. (2008). Texas: Total number of hospitals, 199-2007. State Health

Facts. Retrieved from http://www.statehealthfacts.org


LaViest, T.A., Richardson, W.C., Richardson, N.F., Relosa, R., & Sawaya, N. (2008). The

COA360: A tool for assessing the cultural competency of healthcare organizations.

Journal of Healthcare Management, 53(4), 257-267.

O’Leary, S. C., Federico, S., & Hampers, L.C. (2003). The truth about language barriers: One

residency program’s experience. Pediatrics, 111(5), e569-e573. doi:

10.1542/peds111.5.e569.

Pearson, A., Srivastava, R., Craig, D., Tucker, D., Grinspun, D., Banjok, I. et al. (2007).

Systematic review on embracing cultural diversity for developing and sustaining a

healthy work environment in healthcare. International Journal of Evidence Based

Healthcare, 5, 54-91.

Reynolds, D. (2004). Improving care and interactions with racially and ethnically diverse

populations in healthcare organizations. Journal of Healthcare Management, 49(4), 239-

249.

Schenker, Y., Wang, F., Selig, S.J., Ng, R., & Fernandez, A. (2007). The impact of language

barriers on documentation of informed consent at a hospital with on-site interpreter

services. Journal of General Internal Medicine, 22, 294-299.

United States Census Bureau. (2008, September 8). Newsroom. Retrieved from

http://www.census.gov/Press-

Release/www/releases/archives/facts_for_features_specialeditions/012245.html

United States Department of Health and Human Services. (2007). National standards on

culturally and linguistically appropriate services (CLAS). The Office of Minority Health.

Retrieved from http://www.omhrc.gov/templates/browse.aspx?1v1=2&1v1ID=15


Wilson-Stronks, A., & Galvez, E. (2007). Exploring cultural and linguistic services in the nations

hospitals: A report of findings. The Joint Commission. Retrieved from

http:///www.jointcommission.org

texas woman’s university -...

Documents