By the Innovations Exchange Team
The Innovations Exchange Team: You oversee projects to improve cultural and linguistic competence in hospitals. What are some of the biggest challenges faced by hospitals?
Cindy Brach: Hospitals face many priorities, making it difficult for advocates to focus attention on cultural and linguistic competence. Right now, hospitals are focused on patient safety and the rising costs of care. Similarly, as reimbursement for readmissions is about to change, hospitals face a strong incentive to prevent readmissions. Framing cultural and linguistic competence as a patient safety issue, or potentially as part of the effort to prevent readmission, can help create the case for allocating resources. Another reason it’s challenging to make the case for cultural and linguistic competence is that hospitals often do not have the data to allow them to look at how patient safety correlates to language issues.
Can you describe some of your work to improve cultural and linguistic competence in hospitals?
TeamSTEPPS is a teamwork system funded by the Agency for Healthcare Research and Quality (AHRQ) that is designed for health care professionals. It is aimed at preventing medical errors and improving patient safety through enhanced communication and teamwork skills. We’re currently developing a module that focuses on people with limited English proficiency (LEP). It will consist of a guide with information on how to provide research around medical errors with LEP groups and strategies for addressing the challenges of working with LEP patients. This is an example of an approach to improving cultural and linguistic competence couched in patient safety.
Project RED (Re-Engineering Discharge) is an AHRQ-funded program aimed at improving the hospital discharge process to promote patient safety and prevent rehospitalization. It addresses educating patients about their diagnosis and how to take care of themselves at home, making followup appointments for patients before discharge, and checking in with patients after they leave the hospital to verify medications are taken appropriately. The pilot showed a 30% reduction in rehospitalizations. This pilot, however, was only limited to English-speaking patients and did not deal with diversity, language, or culture. AHRQ is now developing a revised Project RED toolkit to take cultural and linguistic competence into account. The tools will be used in a demonstration project at 10 hospitals. They will then be evaluated and released for public use.
Can you briefly describe innovative approaches to cultural and linguistic competence in hospitals?
There has been a fair amount of discussion recently about providing interpreter services through videoconferencing. Simultaneous interpretation using headsets—almost like in the United Nations – during which the patient hears an interpreter voice as the provider is speaking, has received attention recently, as well, and is starting to be used.
Can you identify best practices that focus on cultural and linguistic competence?
NQF, the National Quality Forum, has created a list of cultural competence preferred practices that are in essence a set of best practices for organizations. The Joint Commission also created a cross-walk of their cultural and linguistic competence standards in comparison to the Office of Minority Health’s CLAS standards. This is a helpful document for organizations interested in developing cultural and linguistic competence.
You are currently helping to review and revise the Office of Minority Health’s standards on Culturally and Linguistically Appropriate Services (CLAS). Can you provide any insight into the updates we can expect to see?
There has been discussion around expanding cultural competence beyond ethnic and racial groups to encompass other vulnerable groups, including the lesbian, gay, bisexual, and transgender community, deaf individuals and populations with disabilities. I am not sure yet how the standards may change, but I am concerned that the current review panel lacks the expertise to adapt the standards to pertain to the needs of these groups.
Including health literacy in the standards has also been discussed. There is increasing recognition that cultural competence and health literacy must be addressed in tandem.
Can you say more about how cultural competence and health literacy relate?
For example, a non-English speaker will not understand a well-written document unless it’s translated into his or her language. However, translation is not in and of itself sufficient. If you try to translate a poorly written document, it will not make sense in either language! You have to be attentive to both the language barriers and the quality of the information communicated to achieve cultural competence and health literacy.
Health literacy has perhaps ascended further than cultural and linguistic competence because health literacy affects everyone. All of us experience low health literacy at times—for example when faced with a new diagnosis or when we’re not feeling well. Cultural and linguistic competence is often seen as a minority health issue and therefore as being relevant to a subpopulation.
Are there other examples of how health literacy concepts and techniques can influence cultural and linguistic competence?
Some health literacy techniques would also be great techniques for improving culturally and linguistic competence. Teach-backs—in which you ask a patient to describe back to you in their own words what you’ve explained or instructions you’ve given—could be used to pick up on cultural misunderstandings as well as health literacy issues. Similarly, asking patients to bring in all the medications they use is now done to identify misunderstandings in prescribed medications. It could also be used to identify alternative and complementary medicines a patient is using but may not have thought to tell their doctor about.
Can you briefly describe your recent work on improving health literacy among racially and ethnically diverse health care consumers?
I am leading the effort to create an Item Set to Address Health Literacy for the Hospital Consumer Assessment of Healthcare Providers and Systems (Hospital CAHPS). This survey asks adult inpatients about their experiences with hospital care and services. The item set includes questions on the quality of interpretation services, including complications in asking for an interpreter, language preferences, language proficiency, and other aspects of experiences with interpreters. This information is important to addressing health literacy because interpretation is key for limited English-proficient patients to understand their diagnoses, instructions for care, and other communications.
AHRQ also commissioned the Health Literacy Universal Precautions Toolkit, which offers primary care providers a way to assess their services for health literacy consideration, raise the awareness of staff, and work on specific issues. It is important to assume that all patients can benefit from clear communication and the clarification of understandings around one’s disease.
You wrote a guide on evidence-based decisionmaking for innovations in health care delivery. What should organizations consider when deciding if they should adopt an innovation?
Would-be adopters should first understand what the innovation is and how it works to see whether it could work in the organization. What is the logic model? Could it work in my organization given its culture, goals, workforce, and resources? What would we have to change? Then, if you determine you could adopt the program, consider if you should. Think about the return on investment, the imperative of the economic advantage, and the organization’s mission. Consider the risks of doing, and not doing, the innovation. If you are still interested, think ahead to the implementation. Adoption often fails when the rubber hits the road so it’s very important to think through what is required once the program is in steady state. Ask how to sustain the program and what strategies you would undertake to scale up the program.
About Cindy Brach, MPP
Cindy Brach is a Senior Health Policy Researcher at AHRQ. She conducts and oversees research on health literacy, cultural and linguistic competence, care management, system design innovations, and Medicaid and State Children’s Health Insurance Program. Brach leads AHRQ’s health literacy and cultural competence activities, such as the development of a TeamSTEPPS module for improving care to patients with limited English proficiency and adapting tools to improve the hospital discharge process for diverse patients. She serves on the Institute of Medicine Roundtable on Health Literacy, the Advisory Group of DiversityRx’s biannual cultural competence conference, the National Quality Forum Cultural Competency Expert Panel, and the National Project Advisory Committee for the CLAS Standards Enhancement of Initiative. Her peer-reviewed articles include “Integrating Literacy, Culture, and Language to Improve Quality of Health Care for Diverse Populations,” “Crossing the Language Chasm,” and “Can Cultural Competency Reduce Ethnic and Racial Health Disparities: A Review and Conceptual Model.” She is also the lead author of “Will It Work Here? A Decisionmaker’s Guide to Adopting Innovations.” Cindy received her Master of Public Policy degree from the University of California, Berkeley, where she was also advanced to PhD candidacy.