TJC proposing new cultural sensitivity standards
TJC proposing new cultural sensitivity standards
Standards would not take effect before 2011
In light of the ever-increasing diversity in patient populations, The Joint Commission (TJC) is proposing revised and additional standards to address communication, cultural competence, and patient-centered care in hospital settings.
TJC accepted public comments on the new requirements from June 8 to July 20. It is anticipated that these ultimately will become part of the typical TJC hospital survey requirements, although they are not expected to be implemented before January 2011.
"Given that racial and ethnic healthcare disparities had been identified and been confirmed by several additional reports, we started looking into this . . . pretty thoroughly, and what we realized was that we weren't really quite sure where healthcare organizations were in term of how they were addressing" the standards being proposed by the Office of Minority Health, according to Amy Wilson-Stronks, project director, health disparities, division of standards and survey methods at TJC.
Through its "Understanding Adverse Events in Limited English Proficient Populations" study, funded by the Commonwealth Fund, TJC was able to establish a link between individuals who had limited English proficiency and the severity of the adverse events they experienced, Wilson-Stronks says.
"So, that is how we've come to now understand what is really important in this issue," she says. "Of course, racial and ethnic disparities are very important [and] we want to ameliorate them, but there are too many other potentially causative factors; and what we can control or improve relates to the actual communication during the health care encounter."
Ethical considerations and input
There was an ethics component to the development of these revised and additional standards, according to Wilson-Stronks.
For example, Matthew Wynia, MD, MPH, FACP, who heads the Chicago-based American Medical Association's Institute of Ethics serves on TJC's advisory panel of 25 people, and he was instrumental in "providing effective provider-patient communications, so the link was perfect in terms of the expertise and his work as an ethicist."
Also, the co-director of this project is "highly involved in medical ethics," says Wilson-Stronks. He is also a member of the oversight body for the AMA's Ethical Force program.
And Wilson-Stronks says that even though patient communication is often discussed generally, "We recognize that that communication is influenced by things, such as culture, as well as language, as well as a physical communication barrier, I think. And I think that cultural differences are where some of those new ethical dilemmas can be raised."
Revisions and additions proposed
All of the reports discussed previously and the proposed revisions and additions can be downloaded on TJC's web site, www.jointcommission.org/PatientSafety/HLC.
The issues addressed in the proposed requirements are broken down as follows:
- staff training and cultural sensitivity;
- staff and licensed independent practitioner training on the use of communication tools;
- use of population- and patient-level demographic data;
- identification of patient communication needs;
- address communication needs across the care continuum;
- provision of language access services and auxiliary aids;
- assessment of patient understanding;
- inclusion of health literacy needs in learning needs assessment;
- collection of patient-level demographic data;
- documentation of the need for mobility assistance;
- documentation of the use of language access services and auxiliary aids;
- accommodation of patients' cultural and personal beliefs;
- accommodation of patients' religious and spiritual practices;
- non-discrimination in care;
- inform patients of right to receive language access services;
- unlimited access to designated patient advocate.
From a human resources perspective, the hospital is to provide orientation on sensitivity to cultural diversity of the staff and the patient population, based on their job duties and responsibilities — contained in element of performance , EP 5 of Standard HR.01.05.03.
For Standard HR.01.05.03, which requires that staff participate in ongoing education and training, there are three new EPs: EP 7, EP 8 and EP 9. Together, they address ongoing sensitivity training, primarily focused on how patient culture can affect the provision of care and communication with patients and among staff, as well as utilizing appropriate communication tools.
TJC also is proposing for the Leadership Chapter, EP 4 for standard L.D.04.03.01, which indicates that the hospital should use available population data to help determine the needs of the population served. That may entail more mundane pieces of information, such as census figures, voter registration data, and school enrollment profiles.
However, TJC also is suggesting the use of much more sensitive demographic data, in the medical record, in an effort to deliver care more precisely, including age, sex, disability, language, race/ethnicity, religion, socioeconomic status, education level, sexual orientation, and gender identity or expression.
Wilson-Stronks acknowledged that certain pieces of this information are sensitive.
"I think what we are going to be seeing as we are considering this and moving forward is — we are really going to have to make sure there is a case that collecting those pieces of demographic information is truly going to have an impact on the provision of care — in a positive way," she says.
That, she notes, may well be a concern of patients, i.e., "Why are you going to collect this — are you going to treat me differently?"
She also said that as physicians and hospitals consider adopting electronic medical records, "protecting the data so that they are not inappropriately made available is very, very important."
A proposed requirement for medical staff indicates that hospitals should educate all licensed independent practitioners on how to use available communication tools, as well as sensitivity to "cultural, religious, and personal values and beliefs."
One of the issues TJC found in its research was that some hospitals may have appropriate policies in place, but the implementation is spotty. When TJC interviewed physicians one-on-one, many were not aware of language services, for example, at their hospitals, even though interpretation services were available to patients. That suggests that there may be problems with training of staff, rather than the policies, she says.
Another proposed requirement specifically addresses communication, in that it requires the identification of the method by which patients want to receive and provide information, which would then be required to be communicated across the continuum of care.
If a patient is a minor or incapacitated, the designated advocate's language preferences would be respected and adhered to.
Proposed requirements for the hospital suggest that institutions should "accommodate the patient's cultural and personal values, beliefs, and preferences." The word "accommodates" was substituted for the previous "respects," Wilson-Stronks says, because the new word "insinuates more of an action."
"And we've also added a note that tried to articulate that this is an action we would expect to be accomplished within reason," she says.
Negotiation in accommodating patient requests is also an area, she says, where ethics consults could come into play. She says that many hospitals have developed negotiated responses to specific patient requests.
The intent of the standards is to encourage hospitals to work with patients to "try to negotiate a reasonable solution to a request, as opposed to, 'That's nice; put it aside."
One of the primary changes involves accommodating a patient's right to have an advocate available in the hospital 24/7.
"There isn't really anything that states that a patient could have an individual available to them," she says. "So, I think what happens is that a patient may be in the hospital, and they may have a health care proxy, for example, but that proxy is only allowed to be with that patient — and have access to that patient — within visiting hours," Wilson-Stronks notes.
Economic implications?
In light of the additional staff training requirements, a natural question is whether — during this current economic downturn — hospitals will have the means to accommodate these requirements.
Although some large, urban or academic hospitals already may be meeting these requirements in their policies, there may be others that would have to implement new policies and new training programs, if these requirements are implemented ultimately by TJC.
"I think that some of the feedback we have gotten from hospitals is: We are already doing this," Wilson-Stronks says, noting that "perhaps they would want to check to see how it is going to be surveyed to make sure that they can demonstrate their compliance during the survey, but there's nothing else they would need to do."
From other institutions, TJC has received feedback "about concerns that education departments have been cut and the resources aren't there — the expertise may not be within the organization."
However, TJC is creating an implementation guide that will "provide hospitals with guidance and resources so that they can do whatever it is that we may ask them," Wilson-Stronks says. Many of those resources will be available to hospitals free of charge.
Source
- Amy Wilson-Stronks, MPP, Principal Investigator, Hospitals, Language and Culture study and Project Director, Health Disparities, The Joint Commission, Oakbrook Terrace, Illinois.
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