Last summer, The Joint Commission’s culturally and linguistically competent patient-centered communication standards became part of the hospital accreditation process. One year later, what difference are they making?
In 2009, Minority Nurse published a Vital Signs story that asked: “Have you ever wished that hospitals had more of an incentive to provide culturally and linguistically competent patient care?” What prompted that question was The Joint Commission’s announcement that it was developing a set of standards that would incorporate the provision of culturally competent patient-centered care into the national requirements for hospital accreditation.
They’ve been a long time coming, but on July 1, 2012, these new and revised standards for patient-centered communication officially became part of the overall accreditation decision. The standards—which are published in a free downloadable implementation guide, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals—require health care organizations to, among other things:
- Identify and effectively meet the oral and written communication needs of all patients, including those with limited English proficiency, hearing or visual impairments, and low health literacy;
- Use highly qualified interpreters and translators, rather than untrained individuals, family members, or bilingual staff;
- Document patients’ language and communication needs in their medical records.
Plus, the standards include two provisions designed to create a more equitable environment for lesbian, gay, bisexual, and transgender (LGBT) patients and their loved ones. One requires hospitals to prohibit discrimination based on sexual orientation and expression of gender identity. The other provides equal hospital visitation rights for same-sex domestic partners by allowing “a family member, friend, or other individual to be present with the patient for emotional support during the course of stay.”
As all nurses know, Joint Commission accreditation reviews are something hospitals take seriously. One year later (or two years in the case of the LGBT standards, which took effect in July 2011 to align with the Centers for Medicare & Medicaid Services’ 2011 visitation rights regulations1), what effect have the patient-centered communication standards had? Are they helping hospitals do a better job of serving culturally diverse patients’ needs? And more importantly, are they starting to make any difference in improving minority health outcomes?
Too Soon to Know
The answer is: It’s still too early to tell.
“We’ve been trying to do some analysis of the scoring data and the requirements for improvement that we’ve seen since last July,” says Christina Cordero, PhD, MPH, associate project director, Department of Standards and Survey Methods, at The Joint Commission. “These data have been somewhat limited because of the time frame. But we’re planning to [look at] that information to see how frequently these issues are being scored, what kinds of situations and comments are coming up on survey, and what our surveyors are seeing on-site.”
In the meantime, anecdotal evidence suggests that most hospitals are at least trying to make sure they’re implementing the standards correctly. For instance, says Cordero, who helped develop the patient-centered communication standards and the Roadmap for Hospitals, The Joint Commission has been fielding many questions about how to implement standard RC.02.01.01, EP 28, which requires hospitals to include patients’ race and ethnicity in their medical records.
“Most of these inquiries have focused on what categories and question formats hospitals should use to collect that information from patients,” she explains. “For example, should they ask about race and ethnicity together in one question or in two separate questions? We responded by publishing FAQ documents on our website to help hospitals implement a data collection system that works for them.”
As for identifying areas where improvement may be needed, The Joint Commission’s initial analysis of data from surveyor site visits seems to indicate that hospitals are finding some of the standards harder to comply with than others.
“The one standard that has been coming up most frequently on-site over the last few months is PC.02.01.21, identification of patients’ language and communication needs during the provision of care, treatment, and services,” Cordero reports. “This may mean that hospitals are struggling more with that issue. Our surveyors are looking at not just the documentation of communication needs but what hospitals are doing to identify and address those needs.”
Is It Enough?
Minority health advocates are also keeping an eye on what The Joint Commission’s evaluation of the standards’ early years will reveal.
“I hope there will be a systematic examination of the outcomes and the impact on the quality of patient care,” says Cora Muñoz, PhD, RN, co-author of the book Transcultural Communication in Nursing. “But the fact that there are now two external bodies that require this—the Office of Minority Health [which developed the Culturally and Linguistically Appropriate Services (CLAS) standards in 20002] and now The Joint Commission—is a step in the right direction.”
Hector Vargas, JD, Executive Director of GLMA: Health Professionals Advancing LGBT Equality (formerly the Gay & Lesbian Medical Association) feels that the patient-centered communication standards are “just one piece of a larger picture of progress we’ve seen over the last few years. These standards, the CMS hospital visitation rules, the  Institute of Medicine report [The Health of LGBT People: Building a Foundation for Better Understanding], Healthy People 2020—which for the first time includes specific LGBT health goals—and the Affordable Care Act have all made a difference in how hospitals are addressing the needs of LGBT patients.”
But some transcultural nursing leaders, such as Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CNS, CTN-A, FAAN, President and Founder of Transcultural C.A.R.E. Associates in Cincinnati, argue that simply having culturally sensitive accreditation standards—or even federal government mandates—in place is not enough. Unless these requirements are vigorously enforced, she believes, there’s no guarantee that hospitals will act on them.
Vargas agrees. “The policies are there at the macro level,” he says, “but we really have to rely on the professionals in the hospitals—nurses in particular, but all members of the health care team—to make sure those policies are enforced.”
Nurses as Communication Champions
What can nurses do to help ensure that their institutions are complying with the standards on an ongoing basis—not just when Joint Commission surveyors show up? Muñoz, who is professor emeritus and an adjunct professor at Capital University School of Nursing, asserts that nurses must be leaders in a constant dialogue about the crucial role culturally competent communication plays in planning and delivering the best possible care for every patient.
“When nurses have a patient who needs language assistance, they must demand that the patient gets those [interpretation] services,” Muñoz adds. “As patient advocates, they should not settle for just getting by, or using family members [as interpreters] when it is convenient. That is not acceptable.”
Laura Hein, PhD, RN, an assistant professor at the University of South Carolina College of Nursing and a member of GLMA’s board of directors, gives two reasons why it’s important for nurses to be involved in championing the standards’ LGBT-inclusive provisions. “One is patient protection and advocacy. The other is to protect the rights of their [LGBT] colleagues, whether they themselves are LGBT-identified or not.” However, she cautions, “If they’re working in a state, or a hospital, that is not accepting of LGBT people, it’s a little trickier for them to be an advocate without endangering their own employment.”
Even though the impact of the patient-centered communication standards is still a work in progress, Muñoz emphasizes that progress is the key word. “At least we have the standards now; we didn’t have them before,” she says. “We’re moving forward. I wish we could move faster. But we’re moving.”
- U.S. Department of Health and Human Services, “Medicare Finalizes New Rules to Require Equal Visitation Rights for All Hospital Patients,” November 17, 2010, www.hhs.gov/news/press/2010pres/11/20101117a.html, accessed March 26, 2013.
- U.S. Department of Health and Human Services, Office of Minority Health, “National Standards on Culturally and Linguistically Appropriate Services (CLAS),” http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15, accessed March 25, 2013.