The Safety Blog

The Safety Blog serves to highlight patient safety news, stories, and initiatives aimed at upholding our mission: safe care for every patient, every time, everywhere.

THE IMPACT OF LANGUAGE & CULTURAL BARRIERS ON PATIENT SAFETY & HEALTH EQUITY

language-barriers

by Anita Sulaiman, Founding Consultant & Trainer
IBEX | Inter-Cultural Business Excellence


If you have ever been in a situation where you do not speak the language of the land and cannot understand or make yourself understood, you know what it is like to face a language barrier. Imagine needing medical attention in that environment.

In any given setting, the inability to effectively communicate can be very limiting and stressful. In a healthcare setting – where even in the happiest of circumstances like the birth of a newborn, people are feeling anxious and vulnerable – that stress is amplified and that limitation has significant repercussions on patient safety, health outcomes as well as health equity.

A DIVERSE LANDSCAPE MEANS DIVERSE NEEDS

One out of five, or over 60 million people in the United States speak a language other than English at home[1]. Forty-two percent of this group is Limited English Proficient (LEP)[2], meaning they speak English less than “very well”. This segment of the U.S. population is at risk of adverse events because of impediments associated with their language ability.

In Washington State, approximately 660,000 people are LEP[3]. Whatever the patient care setting, as this country becomes increasingly diverse, health systems are encountering more and more LEP patients and families from various different cultures. Language and cultural barriers present critical challenges to both providers and patients in ensuring meaningful access[4] to quality care. Recipients of government funding are mandated by a number of laws to provide language access to healthcare services. The reality is many struggle to fulfill this obligation. Our healthcare system, in its current state, is not equipped to operate in an environment where a large section of the constituency requires language assistance.

LEP PATIENTS FACE BARRIERS TO ACCESS FROM STEP ONE

It is easy to forget how much of a barrier language and culture can pose; unless you are a person with limited English proficiency. Simply scheduling an appointment can be an ordeal if you do not speak English. As part of a cultural competency audit I was conducting as a consultant, on several hospitals in different states, I had to make telephone calls to these hospitals as if I was an LEP patient. On one, where I presented myself as a Chinese-speaker, this was what ensued:

“Patient” (in Mandarin): Hello. Good morning. I’d like to see a doctor please. My head is hurting very badly.

Hospital employee answering the phone (in English): Good morning, _ Medical Center. Can I help you?

“Patient”: Hello. I’d like to see a doctor please.

Hospital: Do you speak English?

“Patient”: I speak Chinese. I don’t speak English.

Hospital: Do – you – speak – English?

“Patient”: I’m telling you, I don’t speak English. My English is not good. Can you help me please?

Hospital: You need to speak English if you want to be in this country! [Click. Hangs up.]

This was some time ago and it is an extreme example, but non-English speakers continue to experience variations of this scenario in their encounters with medical facilities every day. Language barriers can preclude meaningful access. In egregious cases, while it is more the rarity than the norm, they face outright discrimination. To compound an already difficult situation, trust becomes an issue. Even when a facility’s staff members are trying their best, lack of training often impedes their ability to provide competent care. Seemingly innocuous actions like using ad hoc or untrained interpreters can and do result in patient harm.

UNADDRESSED LANGUAGE BARRIERS CAN HAVE DEVASTATING EFFECTS

Ineffective communication has been shown to lead to a host of problems. There is plenty of anecdotal and empirical evidence that language and cultural barriers jeopardize a system’s effectiveness and disadvantage people who do not speak or are not fluent speakers of English. Researchers from Boston Medical Center and Boston University School of Public Health found that individuals who do not speak English at home are less likely to receive colorectal cancer screenings than those who do. Their findings[5] demonstrate that language barriers contribute to health disparities. This has important implications. Colorectal cancer is the third most common cancer in the U.S. It is the second leading cause of cancer-related deaths in men, and third in women. Examples abound of medical errors with devastating effects resulting from failure to address these barriers. That is particularly unfortunate, because these are largely avoidable risks.

One of the most (in)famous is the case of 18-year old William Ramirez. He arrived at a South Florida hospital unconscious, after suddenly developing a splitting headache at a school event. Before collapsing, he told his girlfriend, who spoke limited English, “Me siento intoxicado”. When the ambulance arrived, she repeated “intoxicado” to the paramedics who, as minimal Spanish-speakers, misinterpreted it as “intoxicated”. They brought him to the emergency department, where he was treated for a drug overdose. Ramirez woke up paralyzed. Turns out he had a brain hemorrhage, which left him a quadriplegic for life. The bleeding was overlooked until too late. After being in a coma for 48 hours, doctors ordered a CT scan, which revealed that his head was flooded with blood. Apparently, feeling “intoxicado” can also mean “sick to the stomach”, which is a symptom of brain aneurysm. The miscommunication led to a $71 million malpractice lawsuit.

COMMUNICATION BREAKDOWNS CAN HAPPEN AT EVERY LEVEL – AND THEY CAN BE COSTLY

According to a 2015 CRICO Strategies Benchmarking Report, Malpractice Risks in Communication Failures[6], a third of national malpractice claims involve a communication failure. Mixed into that general description is miscommunication due to language barriers. Fifty-five percent of the 23,658 cases (filed from 2009 and 2013) analyzed reflect miscommunication between providers and patients. Twelve percent involve that, as well as breakdowns in communication between two or more healthcare providers, indicating that miscommunication between providers is a significant part of the problem.

These are healthcare quality issues and they can be costly. In the above report, there were 7,149 cases accounting for $1.7 billion of total incurred losses from irreparable patient harm due to communication failures. Reports and studies like this shine a light on risks to patient safety and, conversely, opportunities to mitigate those risks, prevent harm, reduce health disparities and improve safety. They identify specific drivers of these breakdowns, offering organizations actionable data to guide and inform improvement initiatives, strategy formulation and policy-making.

NTEGRITY OF COMMUNICATION IS A CRUCIAL KEY

Language is at the heart of communication and any exchange of information. When there is a breakdown, vital information that both patients and providers rely on is not captured, not delivered, not accurate, delayed or plain incorrect. There is a disconnect between the holder of the information and the person who needs it. That, in turn, can lead to errors, mismanagement and injury. Where multiple providers are part of a care team, the systemic risk is inherent in every link in the entire chain. Integrity of communication is a crucial key to the system’s success. When that integrity is compromised, so is the system’s ability to provide safe and effective care.

A 2007 qualitative study titled “Hospitals, Language and Culture: A Snapshot of the Nation” delved into this intersection between patient safety, language and culture. Their sample – 60 hospitals across the nation – was made up of two groups: the (a) judgment sample, i.e. hospitals making a concerted effort to address patients’ cultural and linguistic needs, handpicked by the research team and (b) stratified sample, i.e. randomly selected hospitals. Among other things, they found:

  • Safety issues related to language tend to be easier to recognize than those related to culture. Twice more hospitals reported identifying a direct relationship between patient safety issues and patients’ linguistic needs than cultural needs.
  • Equal numbers from both groups reported identifying safety issues related to linguistic issues, but 17% more from the judgment group reported issues related to culture. Arguably, making a concerted effort makes a difference.
  • One Northeast region hospital, by stratifying their adverse event data by language, found that there were clusters of adverse events in patients with English as a second language. This connection between language and safety highlighted for them the challenges of providing care to LEP persons.
  • At another hospital, making accommodations around medication self-administration with their Navajo patients, who had varying degrees of English proficiency and health literacy, improved patient understanding and medication compliance.
  • A Midwest region hospital improved their Emergency Department flow by increasing language services and working to better understand the community they serve.

It is clear that addressing language and cultural needs can directly impact safety, outcomes and health equity.

PROVIDERS HAVE A RESPONSIBILITY TO CROSS THE CHASM

Hospital administrators will tell you that the chasm that is language and cultural barriers is not an easy one to cross. But that chasm is also a quality and safety one. It is, therefore, imperative that providers seek to understand it and prioritize efforts to bridge it. As they work to heal and promote health, practitioners have a responsibility to pay particular attention to vulnerable populations and their special needs.

What makes bridging the chasm so challenging? There are many contributing factors. A national survey titled, Hospital Language Services For Patients With LEP[7], listed inability of staff to identify patients who need language services before they arrive at a hospital and cost and reimbursement concerns as the most cited barriers hospitals face in providing language services. Some other obstacles mentioned were lack of tools and training resources, lack of community-level data and staff discomfort with asking patients to provide information on their primary language.

My own experience administering a system-wide program charged with ensuring culturally and linguistically appropriate services, for what was then the largest provider in the Pacific Northwest, gave me valuable insights into many of the operational-level challenges that systems face in providing meaningful access to all populations. Issues include staffing, funding, changing demographics/language needs, interpreter quality and supply, availability of good, up-to-date data, organizational culture, organizational structure, policy and internal processes – each of which impacted our ability to deliver the desired quality throughout the care continuum.

The challenges are daunting, but the benefits of grasping and addressing them are compelling – not only from a mission, but also business standpoint. It makes good business sense to provide safe care – for every patient, every time, everywhere. This, incidentally, is the vision of the Washington Patient Safety Coalition.

WORTH RECOGNIZING: WE ARE ALL PATIENTS

I remember an interesting observation made at HealthPact’s inaugural workshop in 2010[8], where I was involved as a Consumer Representative, and that is: providers, so focused on and immersed in their professional roles, often overlook the fact that we are all patients. One participant, a Risk Manager, noted, “It’s amazing; how do we forget that? We don’t think that, at some point, we are all patients”. It should not be, but it was quite the discovery. You would think it is easy to put yourself in the patient’s shoes; it is not.

The idea to include patients in the important conversation around improving communication was a great one. The people for whom the medical industry exists in the first place have traditionally not been given a seat at the table. Your customers are always the best people to tell you what they need, as well as if and how well their needs are being met. This is a good one to keep in mind. The patient’s perspective is, more often than not, neglected. As many involved in quality improvement efforts are discovering, it can be the most valuable.

EQUAL ACCESS IS A RIGHT, NOT A PRIVILEGE

Lest we forget: Healthcare is a right; so is equal access to care. The words of Martine Pierre-Louis, Director of Interpreter Services at Harborview Medical Center, a stalwart of the cause, offer hope. She shared with me this nugget about her experience: “I have encountered politics, I have encountered bureaucracy, I have encountered things that make me angry. But in all my years of doing this work, I encounter, overwhelmingly, a sense of devotion, compassion and service.”

The goal of ensuring safe, quality care for all is not just commendable and lofty, it is necessary. People’s lives — our lives — and well-being depend on it.

 

ABOUT THE AUTHOR
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Anita Sulaiman is Founding Consultant and Trainer at IBEX Consulting. Her extensive international experience and professional background span public and private sectors, for-profit and not-for-profit enterprises, in industries including aviation/aerospace, healthcare, electronics, retail, manufacturing, hospitality, military/defense and government.Her areas of expertise are communications, leadership development, cultural competency, language access, change management and business process re-engineering.

Ms. Sulaiman is passionate about helping individuals and organizations excel in a global world through executive and business coaching, technical consulting and cross-cultural training.Anita began her career as a management consultant, spearheading organizational transformation initiatives in multi-national corporations for Alexander Proudfoot and REL – global leaders in productivity, quality, and working capital management. This systems background enabled her to take the management of linguistic services at Swedish Medical Center to a new level. She has since helped various healthcare institutions in Washington and other states identify barriers to equal access and formulate strategies to better serve diverse communities.

Anita has continued to stay at the forefront of efforts to improve patient safety, serving on advisory groups and committees for organizations including the Washington Patient Safety Coalition, Foundation for Health Care Quality (Patient & Family Advisory Council) and Washington State Coalition for Language Access.Anita graduated with a Bachelor of Business in Business Administration from the Royal Melbourne Institute of Technology in Australia. She is fluent in Bahasa Indonesia and Malay; and speaks basic Mandarin (Chinese). Anita is happiest when her work involves building bridges – between people, cultures, organizations and countries.


 

[1] Source: U.S. Census Bureau, 2011 American Community Survey

[2] DOJ defines LEP individuals as individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English. LEP individuals may be competent in English for certain types of communication (e.g., speaking or understanding), but still be LEP for other purposes (e.g. reading or writing).

[3] Source: Washington State Office of Financial Management: 2016 Estimates of Population With LEP

[4] DOJ defines meaningful access as language assistance that results in accurate, timely and effective communication at no cost to the LEP individual. For LEP individuals, meaningful access denotes access that is not significantly restricted, delayed or inferior as compared to programs or activities provided to English proficient individuals.

[5] A Linksky, N McIntosh, H Cabral, LE Kazis. Patient-Provider Language Concordance and Colorectal Screening. Journal of General Internal Medicine, 2010; DOI: 10.1007/s11606-010-1512-9

[6] 2015 Comparative Benchmarking System (CBS) Report. CRICO is a division of The Risk Management Foundation of the Harvard Medical Institutions Incorporated.

[7] 2006, by the Health Research & Educational Trust.

[8] HealthPact was started in 2010 as a statewide, multi-stakeholder collaborative created to promote transparency and communication in healthcare. In 2016, it was integrated into the Washington Patient Safety Coalition (WPSC).

 

TAILORING A COMMUNICATION AND RESOLUTION PROGRAM TO YOUR MEDICAL SYSTEM


Organization:
Confluence Health
Project Name/ Title: CRP
Point of Contact: Randal Moseley, MD, FACP, FHM, Medical Director of Quality | randal.moseley@confluencehealth.org


About Confluence Health

Confluence Health is an integrated healthcare delivery system located in North Central Washington. We serve a population of about 250,000 dispersed over 12,000 square miles. Our resources include two hospitals, 13 clinic locations, over 270 physicians covering more than 40 medical specialties and primary care, and 150 advanced practice clinicians.

 

Starting the Journey: CRP Foundations
Communication and Resolution Programs (CRPs) consist of a bundle of strategies to improve response to patient harm events, learn from them, and execute needed changes to prevent similar events in the future. In our quest for a best practice way to handle patient harm events in our system, we found CRP strategies to be culturally very compatible with Confluence Health quality philosophy.

To implement CRP strategies into our system, we began by educating leadership and key operational personnel in CRP principles and methods, and now have top executive support to adopt CRP as the foundation for the majority of our incident response and quality improvement activity within our facilities.

From what we’ve learned, the CRP journey requires:

  • Making a commitment to transparency with patients
  • Employing rigorous event analysis using just culture and human factors principles
  • Supporting the emotional needs of the patient and care team affected by the event
  • Proactively seeking appropriate financial and non-financial resolution for patients
  • Continuously assessing the impact of the program

 

From Vision to Action: Essential Building Blocks
Our core action team leading this work is called the Culture of Safety Committee, with representation from incident management, quality improvement, and members of the senior leadership team. We have used the “key steps” list from the Collaborative for Accountability and Improvement for our roadmap, and these are the lessons and tools we’ve employed:

1. Facilitating the Initial Response:
It is important to have an engaged workforce that is not hesitant to report patient harm events quickly. To gain the confidence of employees, it is critical to operate with just culture principles and a human factors perspective when approaching error events. While this foundation is critical to the success of CRP implementation, this cultural environment is impossible to create quickly. At Confluence, we had a fortunate accidental segue into CRP needs – we had been working on a “speak up” program from the beginning of our organization in 2013.

Our event reporting system, Quantros, gives the option of confidential reporting without alerting the normal management structure to the identity of the reporter, but we discourage truly anonymous reporting due to the information limitations that anonymity creates.

To address immediate clinical, safety and patient/family support needs that may arise with an adverse event, we utilize our “Now” call system. This consists of a rotation of senior leadership team members being available 24/7/365 to respond to serious events within 30 minutes. All members of the organization are empowered to report harm events and serious safety concerns as a “Now” call. Responding senior leadership have the authority to quickly marshal any needed resources the situation may require.

We also recognize the critical importance of having an effective and rapid disclosure discussion with patients and their families following such events. To build on our existing strengths in transitioning to a CRP system, we will soon be training the “Now” call responders to coach providers through this conversation.

Creating a system to meet the emotional needs of the care team involved in the event is a challenge. Our research revealed that Employee Assistance Programs typically fall short of the task, but we could not find a successful system to duplicate that we felt would effectively meet our ideals. In an effort to resolve this challenge, we engaged our Behavioral Health service line to design a system of our own that will involve trained peer support as well as professional Behavioral Health follow up if needed. We also recently hired a PhD psychologist to direct this effort.

Our Incident Management group integrates functions of patient relations as well as risk management. They are involved early in an event to monitor and respond to patient and family needs, facilitate ongoing communication, place holds on bills, and initiate the Root Cause Analysis and Action (RCA2) process.

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2. Adopting Patient Safety and Quality Improvement Activities:

At Confluence, we have adopted the National Patient Safety Foundation RCA2 system. This resource gives a step-by-step guide to implementation of an updated root cause analysis process, and we follow it very closely. We have been impressed by the effectiveness of this method in rapidly gaining actionable information versus traditional root cause analysis techniques. Our Quality and Incident Management teams work together to implement needed changes revealed by this process, engaging all those affected. However, we have difficulties with ownership and accountability, and following up to be sure that change sticks can be challenging. To address this, we have created a new Quality Leadership Council to more effectively coordinate, track, and measure the success of improvement initiatives.

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3. Continuing Patient Engagement and Movement Toward Resolution:
Navigating legal and financial factors consistently and appropriately is key to the process. By CRP principles, when all of the facts are known, our goal is to make a proactive offer of fair financial and non-financial resolution for all harm events. Most health care organizations do this at least some of the time, so it is not an unnatural stretch to consider this for all harm events. One of the main roadblocks we face, and that is faced on a national level, is how to appropriately engage patient legal representation that understands and is supportive of this process.

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4. Disseminating Post-Event Patient Safety and Quality Improvement Lessons Learned:
How best to communicate the teachings gained through this process is also an important consideration for us. Currently, we try to engage all those who could benefit by lessons learned through our quality improvement process. However, it is sometimes difficult to identify all those who might benefit from this information. The ideal way of disseminating this valuable information is a current work in progress.

 

We hope our work will place us in a position soon to take advantage of the WPSC’s new CRP Certification Program.

 

This is not a simple journey, but there are extensive resources available to assist any organization that wishes to create an effective CRP. We encourage others to promote CRP methods in their institutions. It not only is the right thing to do for our patients, but also represents a huge step forward from the traditional “deny and defend” approach to healthcare errors.

 

Resources: